Note : Les descriptions sont présentées dans la langue officielle dans laquelle elles ont été soumises.
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METHODS FOR TREATING A DISEASE OR DISORDER USING
ORAL FORMULATIONS OF CYTIDINE ANALOGS IN
COMBINATION WITH AN ANTI-PD1 OR ANTI-PDLI.
MONOCLONAL ANTIBODY
I. FIELD
[0001] Provided herein are methods for treating a disease or disorder using
oral
formulations of cytidine analogs, or pharmaceutically acceptable salts,
solvates or hydrates
thereof, in combination with an anti-PD1 or anti-PDL1 monoclonal antibody.
Also provided
herein are oral formulations of cytidine analogs, or pharmaceutically
acceptable salts,
solvates or hydrates thereof, in combination with an anti-PD1 or anti-PDL1
monoclonal
antibody that can be used in said methods.
II. BACKGROUND
[0002] Cancer is a major worldwide public health problem; in the United
States alone,
approximately 570,000 cancer-related deaths were expected in 2005. See, e.g.,
Jemal etal.,
CA Cancer J. Gin. 55(1):10-30 (2005). Many types of cancer have been described
in the
medical literature. Examples include cancer of the blood, bone, lung (e.g.,
non-small-cell
lung cancer and small-cell lung cancer), colon, breast, prostate, ovary,
brain, and intestine.
The incidence of cancer continues to climb as the general population ages and
as new forms
of cancer develop. .A continuing need exists for effective therapies to treat
subjects with
cancer.
[0003] Acute myeloid leukemia (AML), also known as acute myelogenous
leukemia or
acute nonlymphocytic leukemia (ANLL), is a cancer of the myeloid line of blood
cells,
characterized by the rapid growth of abnormal white blood cells that
accumulate in the bone
marrow and interfere with the production of normal blood cells. AML is the
most common
acute leukemia affecting adults, and its incidence increases with age.
[0004] Myelodysplastic syndromes (MDS) refers to a diverse group of
hematopoietic
stem cell disorders. MDS affects approximately 40,000-50,000 people in the
U.S. and
75,000-85,000 people in Europe. MDS may be characterized by a cellular marrow
with
impaired morphology and maturation (dysmyelopoiesis), peripheral blood
cytopenias, and a
variable risk of progression to acute leukemia, resulting from ineffective
blood cell
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production. See, e.g., The Merck Manual 953 (17th ed. 1999); List et Oncol.
8:1424 (1990).
[0005] MDS are grouped together because of the presence of dysplastic
changes in one
or more of the hematopoietic lineages including dysplastic changes in the
myeloid,
erythroid, and megakaryocytic series. These changes result in cytopen.ias in
one or more of
the three lineages. Patients afflicted with MDS may develop complications
related to
anemia, neutropenia (infections), and/or thrombocytopenia (bleeding). From
about 10% to
about 70% of patients with MDS may develop acute leukemia. In the early stages
of MDS,
the main cause of cytopenias is increased programmed cell death (apoptosis).
As the
disease progresses, a proliferation of leukemic cells may overwhelm the
healthy marrow.
The disease course differs, with some cases behaving as an indolent disease
and others
behaving aggressively with a clinical course rapidly leading to AML
transformation. The
majority of people with higher risk MDS eventually experience bone marrow
failure. Up to
50% of MDS patients succumb to complications, such as infection or bleeding,
before
progressing to AML.
[0006] Primary and secondary MDS are defined by taking into account
patients' prior
history: previous treatments with chemotherapy, radiotherapy or professional
exposure to
toxic substances are factors delineating secondary MDS (sMDS) from primary
MDS.
Cytogenetically, one difference between the two groups is the complexity of
abnormal
karyotypes; single chromosome aberrations are typical for primary MDS, while
multiple
changes are more frequently seen in secondary disorders. Some drugs may have
specific
targets such as hydroxurea for 17p and topoisomerases inhibitors for 11q23 and
21.0122. The
genetic changes in the malignant cells of MDS result mainly in the loss of
genetic material,
including probable tumor suppressor genes.
[0007] An international group of hematologists, the French-American-British
(FAB)
Cooperative Group, classified MDS into five subgroups, differentiating them
from acute
m.yeloid leukemia. See, e.g., The Merck Manual 954 (17th ed. 1999); Bennett J.
M., et al.,
Ann. Intern. Med., 103(4): 620-5 (1985); and Besa E. C., Med. Clin. North Am.
76(3): 599-
617 (1992). An underlying trilineage dysplastic change in the bone marrow
cells of the
patients is found in all subtypes. Information is available regarding the
pathobiology of
MDS, certain MDS classification systems, and particular methods of treating
and managing
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MDS. See, e.g., U.S. Patent No. 7,189,740 (issued March 13, 2007), which is
incorporated
by reference herein in its entirety. There exists a great need for treating
relapsed or
refractory MDS.
[0008] Nucleoside analogs have been used clinically for the treatment of
viral infections
and cancer. Most nucleoside analogs are classified as anti-metabolites. After
they enter the
cell, nucleoside analogs are successively phosphorylated to nucleoside 5'-mono-
phosphates,
di-phosphates, and tri-phosphates.
[0009] 5-Azacytidine (National Service Center designation NSC-102816; CAS
Registry
Number 320-67-2), also known as azaci.tidine, AZA, or 4-amino-H3-D-
ribofuranosyl-1,3,5-
triazin-2(IH)-one, is currently marketed as the drug product VIDAZA . 5-
Azacytidine is a
nucleoside analog, more specifically a cytidine analog. 5-Azacytidine is an
antagonist of its
related natural nucleoside, cytidine. 5-Azacytidine and 5-aza-2'-deoxycytidine
(also known
as decitabine, an analog of deoxycytidine) are also antagonists of
deoxycytidine. A
structural difference between these cytidine analogs and their related natural
nucleoside is
the presence of a nitrogen at position 5 of the cytosine ring in place of a
carbon. 5-
Azacyti.din.e may be defined as having the molecular formula C81-112N405, a
molecular
weight of 244.21 grams per mole, and the following structure:
NH2
N1
HO
OH OH
5-Azacytidin.e.
[0010] Other members of the class of cytidine analogs include, for example:
1-13-D-
arabinofuranosylcytosine (Cytarabine or ara-C); 5-aza-2'-deoxycytidine
(Decitabine or 5-
aza-CdR); pseudoisocytidine (psi ICR); 5-fluoro-2'-deoxycytidine (FCdR); 2'-
deoxy-2`,2'-
difluorocytidine (Gemcitabine); 5-aza-2'-deoxy-2',2'-di.fluorocytidine; 5-aza-
2'-deoxy-2'-
fluorocytidine; 1-13-D-ribofuranosy1-2(1H)-primidinone (Zebularine); 2',3'-
dideoxy-5-
fluoro-3'-thiacytidine (Emtriva); 2'-cyclocytidine (Ancitabine); 1-13-D-
arabinofuranosy1-5-
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azacytosine (Fazarabine or ara-AC); 6-azacytidine (6-aza-CR); 5,6-dihydro-5-
azacytidine
(d1-1-aza-CR); N4-pentyloxycarbony1-5'-deoxy-5-fluorocytidine (Capecitabin.e);
N4-octadecyl-cytarabine; and elaidic acid cytarabine.
[0011] After its incorporation into replicating DNA, 5-azacytidine or 5-aza-
2'-
deoxycytidine forms a covalent complex with DNA m.ethyltransferases. DNA
methyltransferases are responsible for de novo DNA methylation and for
reproducing
established methylation patterns in daughter DNA. strands of replicating DNA.
Inhibition of
DNA methyltransferases by 5-azacytidine or 5-aza-2'-deoxycytidine leads to DNA
hypomethylation, thereby restoring normal functions to morphologically
dysplastic,
immature hematopoietic cells and cancer cells by re-expression of genes
involved in normal
cell cycle regulation, differentiation and death. The cytotoxic effects of
these cytidine
analogs cause the death of rapidly dividing cells, including cancer cells,
that are no longer
responsive to normal cell growth control mechanisms. 5-azacytidine, unlike 5-
aza-2'-
deoxycytidine, also incorporates into RNA. The cytotoxic effects of
azacitidine may result
from multiple mechanisms, including inhibition of DNA, RNA and protein
synthesis,
incorporation into RNA and DNA., and activation of DNA damage pathways.
[0012] 5-Azacytidine and 5-aza-2'-deoxycytidine have been tested in
clinical trials and
showed significant anti-tumor activity, such as, for example, in the treatment
of MDS,
AML, chronic myelogenous leukemia (CML), acute lymphocytic leukemia (ALL), and
non
Hodgkin's lymphoma (NHL). See, e.g., Aparicio etal., Curr. Opin. Invest. Drugs
3(4): 627-
33 (2002). 5-Azacytidine has undergone NCI-sponsored trials for the treatment
of TADS
and has been approved for treating all FAB subtypes of MDS. See, e.g.,
Kornblith etal., J.
Oncol. 20(10): 2441-2452 (2002); Silverman etal., .1. Clin. OncoL 20(10): 2429-
2440
(2002). 5-Azacytidine may alter the natural course of MDS by diminishing the
transformation to AML through its cytotoxic activity and its inhibition of DNA
methyltransferase. In a Phase III study, 5-azacytidine administered
subcutaneously
significantly prolonged survival and time to .AML transformation or death in
subjects with
higher-risk MDS. See, e.g., P. Fenaux etal., Lancet OncoL, 2009, 10(3):223-32;
Silverman
et al., Blood 106(11): Abstract 2526 (2005).
[0013] Epigenetic silencing of genes encoding tumor specific antigens,
antigen
processing and presentation machinery and pro-inflammatory cytokines and
chemokines
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can be reversed in vitro by treatment of tumor cells with sub-cytotoxic
concentrations of
hypom.ethylating drugs such as 5-aza-cytidine or 5-aza-2-deoxycytidi.ne (D.AC)
(Azacitidine
Investigator's Brochure). Gene expression changes in response to AZA treatment
across a
panel of breast, colorectal and epithelial ovarian cancer (EOC) cell lines
have been
described. AZA. IMmune (AIMs) gene signature comprising 317 pro-immunogenic
genes
was defined. Of the 3 tumor types represented in the panel, EOC lines had the
most
prevalent and pronounced AIM response to A.ZA treatment which activated immune
response pathways and antigen presentation genes (Li, 2014).
[0014] The importance of intact functions of immune surveillance in
controlling
outgrowth of neoplastic transformations has been widely known. High expression
of PD-L1
(programmed death-ligand 1) on tumor cells has been found to correlate with
poor
prognosis and survival in various cancer types including ovarian carcinoma
(Hamanishi,
2007). Preclinical data suggests PD-1 (programmed death-1 or programmed cell
death-1)
pathway as a viable target in ovarian cancer (Maine, 2014; Duraiswam.y 2013).
Clinical data
on PD-1113D-L1 inhibition in EOC are limited but in a Phase 1 study of the
anti-PD-L1
antibody BMS-936559, one of seventeen patients with EOC had an objective
response
(Brahmer, 2012).
[0015] Inhibition of the immune checkpoint with antibodies directed at the
PD-1
receptor on T cells or its ligand (PD-L1) on tumor cells has demonstrated
promising anti-
tumor activity in a number of tumors, including melanoma and non-small cell
lung cancer
(Johnson, 2014; Robert 2014).
[0016] Pembrolizurnab, also known as MK-3475 and Keytruda, is a humanized
monoclonal IgG4 antibody directed against human cell surface receptor PD-1
with potential
immunopotentiating activity. Upon administration, pembrolizumab binds to PD-
.1, an
inhibitory signaling receptor expressed on the surface of activated T cells,
and blocks the
binding to and activation of PD-1 by its ligands, which results in the
activation of T-cell-
mediated immune responses against tumor cells. The ligands for PD-1. include
PD-L1,
which is expressed on antigen presenting cells (APCs) and overexpressed on
certain cancer
cells, and PD-L2, which is primarily expressed on APCs. Activated PD-1
negatively
regulates T-cel I activation through the suppression of the PI3K/Akt pathway.
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[0017] There still exists a significant unmet need for the treatment of
cancers (solid or
blood-borne) and hematologic disorders, in particular those that relapse after
or are
refractory to prior therapeutic treatments. For example, EOC that has relapsed
following a
platinum based regimen, and MDS or AML that is not responding to treatment
with
injectable hypomethylating agents, are a significant unmet medical need.
III. SUMMARY OF INVENTION
[0018] Provided herein is a combination of 5-azacytidine, or a
pharmaceutically
acceptable salt, solvate or hydrate thereof with one or more additional
therapeutic agent(s),
including an anti-PD1 or anti-PDL I monoclonal antibody, that can be used in
all the
methods provided herein.
[0019] Provided herein is a compound for use in a method for treating a
subject having
a disease or disorder, wherein the compound is 5-azacytidine, or a
pharmaceutically
acceptable salt, sol.vate or hydrate thereof and wherein the method comprises
cyclically
administering to the subject a therapeutically effective amount of 5-
azacridine, or a
pharmaceutically acceptable salt, solvate or hydrate thereof, and a
therapeutically effective
amount of an anti-PD1 or anti-PDL1 monoclonal antibody, wherein the 5-
azacytidine, or a
pharmaceutically acceptable salt, solvate or hydrate thereof is administered
orally.
[0020] Provided herein is a combination of 5-azacyti.dine, or a
pharmaceutically
acceptable salt, solvate or hydrate thereof with one or more additional
therapeutic agent(s),
including an anti-PD I or anti-PDL1 monoclonal antibody, that can be used in
all the
methods for treating, preventing or managing a disease or disorder in a
subject. Provided
herein are methods for treating, preventing or managing a disease or disorder
in a subject,
using a cytidin.e analog (e.g. 5-azacyti.din.e), or a salt, solvate, or
hydrate thereof, in
combination with one or more additional therapeutic agent(s), including a PD-1
inhibitor.
Also provided are methods for using a cytidine analog, or a salt, solvate, or
hydrate thereof,
in combination with one or more additional therapeutic agent(s) including a PD-
1 inhibitor
to treat, prevent, or manage diseases and disorders, including disorders
related to abnormal
cell proliferation, hematologic disorders, and immune disorders, among others.
In certain
embodiments, the disease or disorder is cancer. In one embodiment, the cancer
is relapsed
or refractory. In one embodiment, the cancer is a solid tumor. In particular
embodiments,
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the cancer is a relapsed or refractory solid tumor. In a specific embodiment,
the cancer is a
cancer of the ovary or lung among others. In another embodiment, the cancer is
a cancer of
the blood or the lymph. In a specific embodiment, the cancer is AML. In yet
another
embodiment, the hematologic disorder is MDS.
[0021] In certain embodiments, the cytidine analog is formulated in an oral
dosage form
provided herein (e.g., a tablet or a capsule). In one embodiment, the cytidine
analog is
administered orally to a subject in need thereof. In one embodiment, the
cytidine analog is
administered to a subject in need thereof for a sustained period of time. In
one embodiment,
the cytidine analog is administered to a subject in need thereof cyclically
(e.g., dosing for
one or more days, followed by a resting period). In one embodiment, the
cytidine analog is
administered to a subject in need thereof over multiple dosing cycles.
[0022] In certain embodiments, the PD-1 inhibitor is an anti-PD-1 antibody.
In one
embodiment, the antibody is a monoclonal antibody. In one embodiment, the
antibody is a
humanized antibody. In a particular embodiment, the anti-PD-1 monoclonal
antibody is
pembrolizurnab.
[0023] In certain embodiments, the cytidine analog is administered orally
or
parenterally. In a preferred embodiment, the cytidine analog is administered
orally. In
particular embodiments, 5-azacytidine is administered orally. In one
embodiment, the
additional therapeutic agent is administered orally or parenterally. In one
embodiment, the
cytidine analog is administered via the same route as the one or more
additional therapeutic
agent(s). In one embodiment, the cytidine analog is administered via a
different route as the
one or more additional therapeutic agent(s) (e.g., one administered orally and
the other
administered parenteral ly).
[0024] In certain embodiments, the cytidine analog and/or the one or more
additional
therapeutic agent(s) (including, but not limited to an anti-PD 1 or anti-PDL1
monoclonal
antibody) are administered in a particular dosing cycle.
[0025] In certain embodiments, a method for treating a subject having a
disease or
disorder, which comprises cyclically administering to the subject a
therapeutically effective
amount of 5-azacytidine, or a pharmaceutically acceptable salt, solvate or
hydrate thereof,
and a therapeutically effective amount of an anti-PD1 monoclonal antibody,
wherein the 5-
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azacytidine, or a pharmaceutically acceptable salt, solvate or hydrate thereof
is administered
orally.
[0026] In certain embodiments, a method for treating a subject having a
disease or
disorder, which comprises cyclically administering to the subject a
therapeutically effective
amount of 5-azacyti.din.e, or a pharmaceutically acceptable salt, solvate or
hydrate thereof,
and a therapeutically effective amount of an anti-PDL1 monoclonal antibody,
wherein the
5-azacytidine, or a pharmaceutically acceptable salt, sol.vate or hydrate
thereof is
administered orally.
[0027] In certain embodiments, the disease or disorder is a solid tumor or
a hem.atologic
disorder. In specific embodiments, the disease or disorder is MDS, AML,
ovarian cancer,
or non-small cell lung cancer. In certain embodiments, the ovarian cancer is
epithelial
ovarian cancer. In certain embodiments, the epithelial ovarian cancer is
relapsed epithelial
ovarian cancer. In certain embodiments, the disease or disorder is relapsed or
refractory.
In certain embodiments, the subject having a disease or disorder did not
respond to a prior
treatment. In certain embodiments, the prior treatment comprises an injectable
hypom.ethylating agent. In certain embodiments, the prior treatment comprises
a platinum
based regimen. In a specific embodiment, the disease or disorder is MDS or AML
that is
not responding to prior treatment with an injectable hypomethyl.ating agent.
In another
specific embodiment, the disease or disorder is EOC or non-small cell lung
cancer that
relapsed after treatment with a platinum based regimen.
[0028] In certain embodiments, the anti-PD1 monoclonal antibody is a
humanized
monoclonal Ig04 antibody. In one embodiment, the humanized monoclonal Ig04
antibody
is pembrolizumab.
[0029] In certain embodiments, the anti-PDL I monoclonal antibody is a
humanized
monoclonal IgG1 antibody. In one embodiment, the humanized monoclonal IgG1
antibody
is durvalumab.
[0030] In one embodiment, the anti-PD1 monoclonal antibody is
pembroli.zumab, MK.-
3475, pidilizumab, ni.vol.umab (BMS-936558, MDX-1106, or ONO-4538).
[0031] In one embodiment, the anti-PDL1 monoclonal antibody is BMS-936559,
atezolizumab (M1?DL3280A), or durvalumab (MED14736).
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[0032] In one embodiment, the anti-PDL1 monoclonal antibody is durvalumab
(MEDI4736).
[0033] In certain embodiments, the 5-azacytidine, or a pharmaceutically
acceptable salt,
solvate or hydrate thereof is administered for 21 consecutive days followed by
seven
consecutive days of rest in a 28 day cycle. In certain embodiments, the 5-
azacytidine, or a
pharmaceutically acceptable salt, solvate or hydrate thereof is administered
for 14
consecutive days followed by seven consecutive days of rest in a 21 day cycle.
[0034] In certain embodiments, the anti-PD l/anti-PDL I monoclonal antibody
is
administered on days 7 and 21 in a 28 day cycle. In certain embodiments, the
anti-
PD1/anti-PDL1 monoclonal antibody is administered on days 8 and 21 in a 28 day
cycle. In
certain embodiments, the anti-PD1/anti-PDL1 monoclonal antibody is
administered on day
I in a 28 day cycle. In certain embodiments, the anti-PD l/anti-PDL I
monoclonal antibody
is administered on day 1 in a 21 day cycle.
[0035] In certain embodiments, the 5-azacytidine, or a pharmaceutically
acceptable salt,
solvate or hydrate thereof is administered for 21 consecutive days followed by
seven
consecutive days of rest in a 28 day cycle, and wherein the anti-PD 1 /anti-
PDL1 monoclonal
antibody is administered on days 7 and 21 of the 28 day cycle. In certain
embodiments, the
5-azacytidine, or a pharmaceutically acceptable salt, solvate or hydrate
thereof is
administered for 21 consecutive days followed by seven consecutive days of
rest in a 28 day
cycle, and wherein the anti-PDIlanti-PDLI monoclonal antibody is administered
on days 8
and 21 of the 28 day cycle. In certain embodiments, the 5-azacytidine, or a
pharmaceutically acceptable salt, solvate or hydrate thereof is administered
for 21
consecutive days followed by seven consecutive days of rest in a 28 day cycle,
and wherein
the anti-PD 1/anti-PDL1 monoclonal antibody is administered on day 1 of the 28
day cycle.
In a specific embodiment, the disease or disorder is MDS or AML. In a more
specific
embodiment, the MDS or AML is relapsed or refractory. In a particular
embodiment, the
MDS or AML is not responding to treatment with injectable hypomethylating
agents.
[0036] In certain embodiments, the 5-azacytidine, or a pharmaceutically
acceptable salt,
solvate or hydrate thereof is administered for 14 consecutive days followed by
seven
consecutive days of rest in a 21 day cycle, and wherein the anti-PD1/anti-PDL
I monoclonal
antibody is administered on day 1 of the 21 day cycle. In a specific
embodiment, the
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disease or disorder is ovarian cancer or lung cancer. In a more specific
embodiment, the
ovarian cancer is epithelial ovarian cancer, or relapsed or refractory
epithelial ovarian
cancer. In another more specific embodiment, the lung cancer is non-small cell
lung cancer,
or relapsed or refractory non-small cell lung cancer. In a particular
embodiment, the
epithelial ovarian cancer or the non-small cell lung cancer relapsed following
a platinum
based therapy.
[0037] In certain embodiments, the 5-azacytidine, or a pharmaceutically
acceptable salt,
solvate or hydrate thereof is administered in an amount of about 25 mg, about
50 mg, about
75 mg, about 100 mg, about 150 mg, about 200 mg, about 250 mg, about 300 mg,
about 350
mg, about 400 mg, about 500 mg, or about 600 mg. In certain embodiments, the 5-
azacytidine, or a pharmaceutically acceptable salt, solvate or hydrate thereof
is administered
in an amount of about 50 mg, about 100 mg, about 200 mg, about 300 mg, about
400 mg,
about 500 mg, or about 600 mg per day.
[0038] In another embodiment, 5-azacytidine, or a pharmaceutically
acceptable salt,
solvate or hydrate thereof is administered in an amount of about 600 mg per
day. In another
embodiment, 5-azacytidine, or a pharmaceutically acceptable salt, solvate or
hydrate thereof
is administered in an amount of about 500 mg per day. In another embodiment, 5-
azacytidine, or a pharmaceutically acceptable salt, solvate or hydrate thereof
is administered
in an amount of about 400 mg per day. In one embodiment, 5-azacytidine, or a
pharmaceutically acceptable salt, solvate or hydrate thereof is administered
in an amount of
about 300 mg per day. In another embodiment, 5-azacytidine, or a
pharmaceutically
acceptable salt, solvate or hydrate thereof is administered in an amount of
about 200 mg per
day. In another embodiment, 5-azacytidine, or a pharmaceutically acceptable
salt, solvate or
hydrate thereof is administered in an amount of about 100 mg per day. In
another
embodiment, 5-azacytidine, or a pharmaceutically acceptable salt, solvate or
hydrate thereof
is administered in an amount of about 50 mg per day. In certain embodiments, 5-
azacytidine, or a pharmaceutically acceptable salt, solvate or hydrate
thereof, is
administered once per day. in certain embodiments, 5-azacytidine, or a
pharmaceutically
acceptable salt, solvate or hydrate thereof, is administered twice per day. In
one
embodiment, 5-azacytidine or a pharmaceutically acceptable salt, solvate or
hydrate thereof
is administered in an amount of about 200 mg, about 150 mg, or about 100 mg
twice per
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day. In one embodiment, 5-azacytidine or a pharmaceutically acceptable salt,
solvate or
hydrate thereof is administered in an amount of about 200 mg twice per day. In
one
embodiment, 5-azacytidine or a pharmaceutically acceptable salt, solvate or
hydrate thereof
is administered in an amount of about 150 mg twice per day. In one embodiment,
5-
azacytidine or a pharmaceutically acceptable salt, solvate or hydrate thereof
is administered
in an amount of about 100 mg twice per day.
[0039] In certain embodiments, the anti-PD 1 /anti-PDL1 monoclonal antibody
is
administered parenterally. In certain embodiments, the anti-PD1/anti-PDL1
monoclonal
antibody is administered in an amount of about 0.5 mg/Kg (about 0.5 mg of anti-
PD1/anti-
PDL1 monoclonal antibody per kilogram of a subject's mass), about 1 mg/Kg,
about 2
mg/Kg, about 3 mg/Kg, about 4 mg/Kg, about 5 mg/Kg, about 6 mg/Kg, about 7
mg/Kg,
about 8 mg/Kg, about 9 mg/Kg, about 10 mg/Kg, about 11 mg/Kg, about 12 mg/Kg,
about
13 mg/Kg, about 14 mg/Kg, about 15 mg/Kg, about 16 mg/Kg, about 17 mg/Kg,
about 18
mg/Kg, about 19 mg/Kg, or about 20 mg/Kg. In a specific embodiment, the anti-
PD1/anti-
PDL1 monoclonal antibody is administered intravenously in an amount of about
20 mg/Kg
per day. In a specific embodiment, the anti-PD1/anti-PDL1 monoclonal antibody
is
administered intravenously in an amount of about 19 mg/Kg per day. In a
specific
embodiment, the anti-PDI/anti-PDL1 monoclonal antibody is administered
intravenously in
an amount of about 18 mg/Kg per day. In a specific embodiment, the anti-PD
1/anti-PDL1
monoclonal antibody is administered intravenously in an amount of about 17
mg/Kg per
day. In a specific embodiment, the anti-PD1/anti-PDL1 monoclonal antibody is
administered intravenously in an amount of about 16 mg/Kg per day. In a
specific
embodiment, the anti-l?Dl/anti-PDL I monoclonal antibody is administered
intravenously in
an amount of about 15 mg/Kg per day. In a specific embodiment, the anti-
PDI/anti-PDL1
monoclonal antibody is administered intravenously in an amount of about 14
mg/Kg per
day. In a specific embodiment, the anti-PD1/anti-PDL1 monoclonal antibody is
administered intravenously in an amount of about 13 mg/Kg per day. In a
specific
embodiment, the anti-l?Dl/anti-PDL I monoclonal antibody is administered
intravenously in
an amount of about 12 mg/Kg per day. In a specific embodiment, the anti-
PDI/anti-PDL I
monoclonal antibody is administered intravenously in an amount of about 11
mg/Kg per
day. In a specific embodiment, the anti-PD1/anti-PDL1 monoclonal antibody is
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administered intravenously in an amount of about 10 mg/Kg per day. In a
specific
embodiment, the anti-PD1./anti-PDL I monoclonal antibody is administered
intravenously in
an amount of about 9 mg/Kg per day. In a specific embodiment, the anti-
PD1/anti-PDL1
monoclonal antibody is administered intravenously in an amount of about 8
mg/Kg per day.
In a specific embodiment, the anti-PD I /anti-PDL1 monoclonal antibody is
administered
intravenously in an amount of about 7 mg/Kg per day. In a specific embodiment,
the anti-
PD1./anti-PDL I monocl.onal antibody is administered intravenously in an
amount of about 6
mg/Kg per day. In a specific embodiment, the anti-PD1 or anti-PDL1 monoclonal
antibody
is administered intravenously in an amount of about 5 mg/Kg. In a specific
embodiment, the
anti-PDI/anti-PDL1 monoclonal antibody is administered intravenously in an
amount of
about 4 mg/Kg per day. In a specific embodiment, the anti-PDI/anti-PDL I
monoclonal
antibody is administered intravenously in an amount of about 3 mg/Kg per day.
In a specific
embodiment, the anti-PDI/anti-PDL I monoclonal antibody is administered
intravenously in
an amount of about 2 mg/Kg per day. In a specific embodiment, the anti-
PD1/anti-PDL1
monoclonal antibody is administered intravenously in an amount of about 1
mg/Kg per day.
In a specific embodiment, the anti-PDI/anti-PDLI monoclonal antibody is
administered
intravenously in an amount of about 0.5 mg/Kg per day. In a specific
embodiment, the anti-
PD I or anti-PDL I monoclonal antibody is administered intravenously in an
amount of
about 1,500 mg per day. In a specific embodiment, the anti-PD1 or anti-PDL1
monoclonal
antibody is administered in an amount of about 1,500 mg per day on day 1 in a
28 day
cycle. in a particular embodiment, the anti-PD1./anti-PDL I monocl.onal
antibody is
administered intravenously in an amount of about 10 mg/Kg per day on dayl in a
28 day
cycle, days 7 and 21 in a 28 day cycle, or on days 8 and 21 in a 28 day cycle.
In a particular
embodiment, the anti-PDVanti-PDL I monoclonal antibody is administered
intravenously in
an amount of about 10 mg/Kg per day on day! in a 28 day cycle. In a particular
embodiment, the anti-PDI/anti-PDL1 monoclonal antibody is administered
intravenously in
an amount of about 10 mg/Kg per day on days 7 and 21 in a 28 day cycle. In a
particular
embodiment, the anti-l?Dl/anti-PDL I monoclonal antibody is administered
intravenously in
an amount of about 10 mg/Kg per day on days 8 and 21 in a 28 day cycle. In a
particular
embodiment, the anti-PD1./anti-PDL1 monocl.onal antibody is administered
intravenously in
an amount of about 5 mg/Kg per day on days 7 and 21 in a 28 day cycle. In one
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embodiment, the anti-PD1 monoclonal antibody is pembrolizumab and is
administered as a
30 minute i.v. infusion.
[0040] In one embodiment, the anti-PDI monoclonal antibody is MK-3475 and
is
administered as a 30 minute i.v. infusion.
[0041] In one embodiment, the anti-PD! monoclonal antibody is pidilizumab
and is
administered as a 30 minute i.v. infusion.
[0042] In one embodiment, the anti-PD I monoclonal antibody is nivolumab
(BMS-
936558, MDX-1106, or ONO-4538) and is administered as a 30 minute i.v.
infusion.
[0043] In one embodiment, the anti-PDL1 monoclonal antibody is atezolizumab
(MPDL3280A) and is administered as a 30 minute i.v. infusion.
[0044] In one embodiment, the anti-PDL1 monoclonal antibody is durvalumab
(MEDI4736) and is administered as a 30 minute i.v. infusion. In one
embodiment,
durvalumab (MEDI4736) is administered on Day I of each 28-day treatment cycle
as a
single 1500 mg IV infusion.
[0045] In certain embodiments, 5-azacytidine or a pharmaceutically
acceptable salt,
solvate or hydrate thereof is in a form of a capsule, tablet or caplet.
[0046] In certain embodiments, the method further comprises administering a
therapeutically effective amount of an additional active agent.
[0047] In a specific embodiment, the subject is a human.
[0048] In certain embodiments, the cytidine analog is 5-azacytidine. In
other
embodiments, the cytidine analog is 5-aza-2'-deoxycytidine (decitabine or 5-
aza-CdR). In
yet other embodiments, the cytidine analog is, for example: 1-3-D-
arabinofuranosylcytosine
(Cytarabine or ara-C); pseudoisocytidine (psi ICR); 5-fluoro-2'-deoxycytidine
(FCdR); 2'-
deoxy-2',2'-difluorocyfidine (Gemcitabine); 5-aza-2'-deoxy-2',2'-
difluorocytidine; 5-aza-2'-
deoxy-2'-fluorocytidin.e;1-13-D-ribofuranosy1-2(1H)-pyrimidinone
(Zebularin.e); 2',3'-
dideoxy-5-fluoro-3'-thiacytidine (Emtriva); 2'-cyclocytidine (Ancitabine); 1-0-
D-
arabinofuranosy1-5-azacytosine (Fazarabine or ara-AC); 6-azacyti.din.e (6-aza-
CR); 5,6-
dihydro-5-azacytidine (dH-aza-CR); N4 pen.tyloxycarbon.y1-5'-deoxy-5-
fluorocytidine
(Capecitabine); N4 octadecyl-cytarabine; elaidic acid cytarabine; or their
derivatives or
related analogs.
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[0049] Certain embodiments herein provide compositions that are single unit
dosage
forms comprising a cytidine analog. Certain embodiments herein provide
compositions that
are non-enteric-coated. Certain embodiments herein provide compositions that
are tablets
comprising a non-enteric coating. Certain embodiments herein provide
compositions that
are tablets comprising a cytidine analog. Certain embodiments herein provide
compositions
that are capsules comprising a cytidine analog. In certain embodiments, the
single unit
dosage forms optionally further contain one or more excipients. In certain
embodiments,
the tablets optionally further contain one or more excipients. In other
embodiments, the
capsules optionally further contain one or more excipients. In certain
embodiments, the
composition is a tablet that effects an immediate release of the API upon oral
administration. In other embodiments, the composition is a tablet that effects
a controlled
release of the API substantially in the stomach. In other embodiments, the
composition is a
tablet that effects a controlled release of the API substantially in the
stomach and the upper
intestine. in certain embodiments, the composition is a capsule that effects
an immediate
release of the API upon oral administration. In other embodiments, the
composition is a
capsule that effects a controlled release of the API substantially in the
stomach. In other
embodiments, the composition is a capsule that effects a controlled release of
the API
substantially in the stomach and the upper intestine. In particular
embodiments, the tablet
contains a drug core that comprises a cytidine analog, and optionally further
contains a
coating of the drug core, wherein the coating is applied to the drug core
using an aqueous
solvent, such as, for example, water, or non-aqueous solvent, such as, for
example ethanol.
[0050] Certain embodiments herein provide methods of using the formulations
provided
herein to treat, prevent, or manage diseases or disorders including, e.g.,
cancer, disorders
related to abnormal cell proliferation, solid tumors, hematologic disorders,
or immune
disorders. In certain embodiments, the formulations of cytidine analogs are
orally
administered to subjects in need thereof to treat, prevent, or manage a
cancer; or a
hematological disorder, such as, for example, MDS, AML, ALL, CMI.õ NHL,
leukemia,
lymphoma, or multiple m.yeloma; or a solid tumor, such as, for example,
sarcoma,
melanoma, carcinoma, or cancer of the colon, breast, ovary, gastrointestinal
system, kidney,
bladder, lung (e.g., non-small-cell lung cancer and small-cell lung cancer),
testicle, prostate,
stomach, pancreas, liver, head and neck, brain, skin, or bone, among others.
In particular
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embodiments, the cancer is a cancer of the bladder, ovary, pancreas, lung,
colon, head and
neck, breast, or skin. In particular embodiments, the cancer is a cancer of
the bladder,
ovary, pancreas, lung, or colon. In certain embodiments, the cancer is
refractory. In certain
embodiments, the cancer is relapsed. In certain embodiments, the cancer is
metastatic. In
certain embodiments, the formulations of cytidine analogs are orally
administered to
subjects in need thereof to treat, prevent, or manage an immune disorder. In
certain
embodiments, the oral formulations provided herein are co-administered with
one or more
therapeutic agents to provide a synergistic therapeutic effect in subjects in
need thereof. In
certain embodiments, the oral formulations provided herein are co-administered
with one or
more therapeutic agents to provide a resensitization effect in subjects in
need thereof. The
co-administered agents may be a cancer therapeutic agent, as described herein.
In certain
embodiments, the co-administered agent(s) may be dosed, e.g., orally or by
injection. in
certain embodiments, the cytidine and/or the co-administered agent(s) may be
dosed
cyclically.
[0051] In certain embodiments, provided herein are tablets containing 5-
azacytidine and
methods for making and using the tablets to treat cancer, disorders related to
abnormal cell
proliferation, or hematologic disorders. In certain embodiments, the tablets
optionally
further contain one or more excipients such as, for example, glidants,
diluents, lubricants,
colorants, disintegrants, granulating agents, binding agents, polymers, and/or
coating agents.
Examples of ingredients useful in preparing certain formulations provided
herein are
described in, e.g., Etter et al., U.S. Patent Application Publication No.
2008/0057086 (App.
No. 11/849,958), which is incorporated herein by reference in its entirety.
[0052] In certain embodiments provided herein are methods of using the
formulations
provided herein to treat, prevent, or manage diseases or disorders including,
e.g., non-small
lung cancer (NSCLC) by administering one or more cytidine analogs to subjects
having
NSCLC. In certain embodiments, the methods comprise treating, preventing or
managing
certain types of NSCLC, including but not limited to, epidermoid or squamous
cell
carcinoma, large cell carcinoma, adenocarci.noma, adenosquamous carcinoma,
carcinomas
with pleomorphic, sarcomatoid or sarcomatous elements, carcinoid tumor,
carcinomas of
salivary-gland, and unclassified carcinoma. In certain embodiments, the
methods comprise
treating, preventing or managing certain stages of NSCLC, including but not
limited to,
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occult carcinoma, Stage 0, Stage IA, Stage IB, Stage IIA, Stage IIB, Stage
IIIA, Stage IIIB,
and Stage IV, in a subject having NSCLC. In certain embodiments, the methods
comprise
treating or managing NSCLC in a subject having particular NSCLC cell types. In
certain
embodiments, the cytidine analog is 5-azacytidine (azacitidine). In certain
embodiments,
the cytidine analog is 5-aza-2'-deoxycytidine (decitabine). In certain
embodiments, the
methods comprise co-administering two or more active agents. In certain
embodiments, the
active agent is an anti-PDI/anti-PDL1 monoclonal antibody. In certain
embodiments, the
active agent is pembrolizumab, MK-3475, pidilizumab, Nivolumab (BMS-936558,
MDX-
1106, or ONO-4538). In certain embodiments, the active agent is BMS-936559,
atezolizumab (MPDL3280A), or durvalumab (MEDI4736). In certain embodiments,
the
methods comprise treating, preventing or managing NSCLC using one or more of
the
methods provided herein, together with one or more of the treatments selected
from surgery,
chemotherapy, immunotherapy, targeted therapy, and radiation therapy.
[0053] Certain embodiments herein provide methods of treating certain NSCLC
cell
types, including but not limited to, A549, H1975, H23, H460, and/or H1299, in
a subject
having NSCLC. Particular methods comprise identifying the presence of at least
one
NSCLC cell type, including but not limited to, A549, H1975, H23, H460, and/or
H1299, in
a subject having NSCLC. Particular methods comprise administering one or more
cytidine
analogs to a subject having NSCLC to treat one or more NSCLC cell types,
including but
not limited to, A549, H1975, H23, H460, and/or H1299. Particular methods
comprise
administering 5-azacytidine to a subject having NSCLC to treat one or more
NSCLC cell
types, including but not limited to, A549, H1975, H23, H460, and/or H1299.
Particular
embodiments herein provide methods for treating a subject with NSCLC by
adm.inistering
5-azacytidine to the subject, wherein the NSCLC includes a cell type selected
from A549,
H1975,1-123, 171460, and H1299.
[0054] Certain embodiments herein provide methods of treating, preventing
or
managing certain types of NSCLC, including but not limited to, (1) squamous
cell
carcinoma, including but not limited to, papillary, clear cell, small cell,
and basaloid
carcinoma; (2) adenocarcinoma, including but not limited to, acinar,
papillary,
bronch.ioloalveolar carcinoma (nonmucinous, mucinous, mixed mucinous and
nonmucinous
or indeterminate cell type), solid adenocarcinoma with mucin, adenocarcinoma
with mixed
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subtypes, and other variants including well-differentiated fetal
adenocarcinoma, mucinous
(colloid) adenocarcinom.a, mucinous cystadenocarcinoma, signet ring
adenocarcinoma, and
clear cell adenocarcinoma; (3) large cell carcinoma, including but not limited
to, large cell
neuroendocrine carcinoma, combined large cell neuroendocrine carcinoma,
basaloid
carcinoma, lym.phoepitheli.oma-like carcinoma, clear cell carcinoma, and large
cell
carcinoma with rhabdoid phenotype; (4) adenosquamous carcinoma; (5) carcinomas
with
pleomorphic, sarcomatoid, or sarcomatous elements, including but not limited
to,
carcinomas with spindle and/or giant cells, spindle cell carcinoma, giant cell
carcinoma,
carcinosarcoma, and pulmonary blastoma; (6) carcinoid tumor, including but not
limited to,
typical carcinoid and atypical carcinoid; (7) carcinomas of salivary-gland,
including but not
limited to, mucoepidermoid carcinoma and adenoid cystic carcinoma; and (8)
unclassified
carcinoma. Particular embodiments herein provide methods of treating,
preventing or
managing NSCLC in the primary tumor, lymph nodes, and/or distant metastasis,
in a subject
having NSCLC. Particular embodiments herein provide methods of treating NSCLC
in a
subject having surgically resectable NSCLC, locally or regionally advanced
NSCLC, and/or
distant metastatic NSCLC.
[0055] Certain
embodiments herein provide, inter alia, pharmaceutical compositions
comprising a therapeutically effective amount of 5-azacytidine, wherein the
composition
releases the 5-azacytidine substantially in the stomach following oral
administration to a
subject. Further embodiments provide the aforementioned compositions, which:
are
immediate release compositions; do not have an enteric coating (ie., are non-
enteric-
coated); are tablets; are capsules; further comprise an excipient selected
from any excipient
disclosed herein; further comprise a permeation enhancer; further comprise d-
alpha-
tocopheryl polyethylene glycol 1000 succinate; further comprise a permeation
enhancer in
the formulation at about 2% by weight relative to the total weight of the
formulation; are
essentially free of a cytidine deaminase inhibitor; are essentially free of
tetrahydrouridine;
have an amount of 5-azacytidin.e of at least about 40 mg; have an amount of 5-
azacytidine
of at least about 400 mg; have an amount of 5-azacytidine of at least about
1000 mg;
achieve an area-under-the-curve value of at least about 200 ng-herriL
following oral
administration to a subject; achieve an area-under-the-curve value of at least
about 400 ng-
hr/mL following oral administration to a subject; achieve a maximum plasma
concentration
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of at least about 100 ng/mL following oral administration to a subject;
achieve a maximum
plasma concentration of at least about 200 ng/mL following oral administration
to a subject;
achieve a ti.m.e to maximum plasma concentration of less than about 90 minutes
following
oral administration to a subject; and/or achieve a time to maximum plasma
concentration of
less than about 60 minutes following oral administration to a subject.
[0056] Certain embodiments herein provide a pharmaceutical composition for
oral
administration comprising a therapeutically effective amount of 5-azacytidine,
which
releases the 5-azacytidine substantially in the stomach and achieves an area-
under-the-curve
value of at least about 200 ng-hr/mL following oral administration.
[0057] Certain embodiments herein provide a pharmaceutical composition for
oral
administration comprising a therapeutically effective amount of 5-azacytidine,
which
releases the 5-azacyti.dine substantially in the stomach and achieves an area-
under-the-curve
value of at least about 400 ng-hr/mL following oral administration.
[0058] Certain embodiments herein provide a pharmaceutical composition for
oral
administration comprising a therapeutically effective amount of 5-azacytidine,
which
releases the 5-azacytidine substantially in the stomach and achieves a maximum
plasma
concentration of at least about 100 ng/mL following oral administration.
[0059] Certain embodiments herein provide a pharmaceutical composition for
oral
administration comprising a therapeutically effective amount of 5-azacytidine,
which
releases the 5-azacytidine substantially in the stomach and achieves a maximum
plasma
concentration of at least about 200 ng/mL following oral administration.
[0060] Certain embodiments herein provide a pharmaceutical composition for
oral
administration comprising a therapeutically effective amount of 5-azacytidine,
which
releases the 5-azacytidine substantially in the stomach and achieves a time to
maximum
plasma concentration of, e.g., less than about 6 hr, less than about 5 hr,
less than about 4 hr,
less than about 3 hr, less than about 2.5 hr, less than about 2 hr, less than
about 1.5 hr, less
than about 1 hr, less than about 45 min, or less than about 30 min following
oral
administration. In specific embodiments, the presence of food may affect
(e.g., extend) the
total exposure and/or time to maximum plasma concentration.
[0061] Certain embodiments herein provide a pharmaceutical composition for
oral
administration comprising a therapeutically effective amount of 5-azacytidine,
which
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releases the 5-azacytidine substantially in the stomach and achieves a time to
maximum
plasma concentration of less than about 60 minutes following oral
administration.
[0062] Certain embodiments herein provide any of the aforementioned
compositions, as
single unit dosage forms, tablets, or capsules.
[0063] Certain embodiments herein provide, inter alia, methods for treating
a subject
having a disease associated with abnormal cell proliferation, comprising
orally
administering to the subject a pharmaceutical composition comprising a
therapeutically
effective amount of 5-azacytidine, wherein the composition releases the 5-
azacytidine
substantially in the stomach following oral administration to the subject.
Further
embodiments herein provide the aforementioned methods, in which: the disease
is
myelodysplastic syndrome; the disease is acute myelogenous leukemia; the
method further
comprises co-administering to the subject in need thereof an additional
therapeutic agent
selected from any additional therapeutic agent disclosed herein; the
composition is an
immediate release composition; the composition does not have an enteric
coating; the
composition further comprises a permeation enhancer; the composition further
comprises
the permeation enhancer d-alpha-tocopheryl polyethylene glycol 1000 succinate;
the
composition further comprises d-alpha-tocopheryl polyethylene glycol 1000
succinate in the
formulation at about 2% by weight relative to the total weight of the
formulation; the
method further comprises not co-administering a cytidine dearninase inhibitor
with the
cytidine analog; the composition is a single unit dosage form; the composition
is a tablet;
the composition is a capsule; the composition further comprises an excipient
selected from
any excipient disclosed herein; the amount of 5-azacytidine is at least about
40 mg; the
amount of 5-azacyti.din.e is at least about 400 mg; the amount of 5-
azacyti.dine is at least
about 1000 mg; the method achieves an area-under-the-curve value of at least
about 200 ng-
hr/mI., following oral administration to the subject; the method achieves an
area-under-the-
curve value of at least about 400 ng-11r/mL following oral administration to
the subject; the
method achieves a maximum plasma concentration of at least about 100 n.g/m1.,
following
oral administration to the subject; the method achieves a maximum. plasma
concentration of
at least about 200 ng/mL following oral administration to the subject; the
method achieves a
ti.m.e to maxi.m.um. plasma concentration of less than about 90 minutes
following oral
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administration to the subject; and/or the method achieves a time to maximum
plasma
concentration of less than about 60 minutes following oral administration to
the subject
[0064] Certain
embodiments herein provide, inter alia, pharmaceutical compositions
comprising a therapeutically effective amount of 5-azacytidine, wherein the
compositions
are for treating a disease or disorder associated with abnormal cell
proliferation, wherein the
compositions are prepared for oral administration, and wherein the
compositions are
prepared for release of the 5-azacytidine substantially in the stomach.
Further embodiments
herein provide the aforementioned compositions, which: have an amount of 5-
azacytidine
of about 40 mg, about 400 mg, or about 1000 mg; are prepared to achieve an
area-under-
the-curve value of at least about 200 ng-hr/ml, or 400 ng-hr/mL following oral
administration; are prepared to achieve a maximum plasma concentration of at
least about
100 ng/mL or 200 ng/mL following oral administration; are prepared to achieve
a time to
maximum plasma concentration of less than about 60 minutes or 90 minutes after
being
administered; are prepared in the form of an immediate release composition;
are prepared
for oral administration in combination with an additional therapeutic agent
selected from
any additional therapeutic agent disclosed herein; are for treating
myelodysplastic syndrome
or acute myelogenous leukemia; further comprise a permeation enhancer; which
further
comprise the permeation enhancer d-alpha-tocopheryi polyethylene glycol 1000
succinate;
are single unit dosage forms; are tablets or capsules; and/or further comprise
an excipient
selected from any excipient disclosed herein.
[0065] Certain
embodiments herein provide, inter alia, uses of 5-azacytidine for the
preparation of a pharmaceutical composition for treating a disease associated
with abnormal
cell proliferation, wherein the composition is prepared for oral
administration, and wherein
the composition is prepared for release of the 5-azacytidine substantially in
the stomach.
Further embodiments herein provide the aforementioned uses, in which: the
disease is
myelodysplastic syndrome or acute myelogenous leukemia; the amount of 5-
azacytidine is
selected from. any amount disclosed herein; and/or the composition is prepared
for
immediate release. Further embodiments provide, inter alia, methods for
treating a subject
having a disease or disorder provided herein by administering a pharmaceutical
compositions provided herein, wherein the treatment results in improved
survival of the
subject.
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IV. BRIEF DESCRIPTION OF THE DRAWINGS
[0066] Figure 1 depicts oral 5-azacytidine/pembrolizumab study flow.
[0067] Figure 2 depicts a dosing regimen.
[0068] Figure 3 depicts a flow diagram of a phase I design.
[0069] Figure 4 depicts a flow diagram of a phase II design.
[0070] Figure 5 depicts a flow diagram of next steps of study.
[0071] Figure 6 depicts Safety run-in phase study design.
[0072] Figure 7 depicts treatment phase study design.
V. DETAILED DESCRIPTION
[0073] Unless defined otherwise, all technical and scientific terms used
herein have the
same meaning as commonly understood by one of ordinary skill in the art. All
publications
and patents referred to herein are incorporated by reference herein in their
entireties.
A. Definitions
[0074] As used in the specification and the accompanying claims, the
indefinite articles
"a" and "an" and the definite article "the" include plural as well as singular
referents, unless
the context clearly dictates otherwise.
[0075] The term "about" or "approximately" means an acceptable error for a
particular
value as determined by one of ordinary skill in the art, which depends in part
on how the
value is measured or determined. In certain embodiments, the term "about" or
"approximately" means within 1, 2, 3, or 4 standard deviations. In certain
embodiments, the
term "about" or "approximately" means within 30%, 25%, 20%, 15%, 10%, 9%, 8%,
7%,
6%, 5%, 4%, 3%, 2%, 1%, 0.5%, 0.1%, or 0.05% of a given value or range.
[0076] As used herein, and unless otherwise specified, the terms "treat,"
"treating" and.
"treatment" refer to the eradication or amelioration of a disease or disorder,
or of one or
more symptoms associated with the disease or disorder. In certain embodiments,
the terms
refer to minimizing the spread or worsening of the disease or disorder
resulting from the
administration of one or more prophylactic or therapeutic agents to a subject
with such a
disease or disorder. In some embodiments, the terms refer to the
administration of a
compound or dosage form provided herein, with or without one or more
additional active
agent(s), after the onset of symptoms of the particular disease.
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[0077] As used herein, and unless otherwise specified, the terms "prevent,"
"preventing" and "prevention" refer to the prevention of the onset, recurrence
or spread of a
disease or disorder, or of one or more symptom thereof. In certain
embodiments, the terms
refer to the treatment with or administration of a compound or dosage form
provided herein,
with or without one or more other additional active agent(s), prior to the
onset of symptoms,
particularly to subjects at risk of disease or disorders provided herein. The
terms encompass
the inhibition or reduction of a symptom. of the particular disease. Subjects
with familial
history of a disease in particular are candidates for preventive regimens in
certain
embodiments. In addition, subjects who have a history of recurring symptoms
are also
potential candidates for prevention. In this regard, the term "prevention" may
be
interchangeably used with the term "prophylactic treatment."
[0078] As used herein, and unless otherwise specified, the terms "manage,"
"managing"
and "management" refer to preventing or slowing the progression, spread or
worsening of a
disease or disorder, or of one or more symptoms thereof. Often, the beneficial
effects that a
subject derives from a prophylactic and/or therapeutic agent do not result in
a cure of the
disease or disorder. In this regard, the term "managing" encompasses treating
a subject who
had suffered from the particular disease in an attempt to prevent or minimize
the recurrence
of the disease.
[0079] As used herein, amelioration of the symptoms of a particular
disorder by
administration of a particular pharmaceutical composition refers to any
lessening, whether
permanent or temporary, lasting or transient, that can be attributed to or
associated with
administration of the composition.
[0080] As used herein, and unless otherwise specified, the terms
"therapeutically
effective amount" and "effective amount" of a compound mean an amount
sufficient to
provide a therapeutic benefit in the treatment or management of a disease or
disorder, or to
delay or minimize one or more symptoms associated with the disease or
disorder. A
"therapeutically effective amount" and "effective amount" of a compound mean
an amount
of therapeutic agent, alone or in combination with one or more other agent(s),
which
provides a therapeutic benefit in the treatment or management of the disease
or disorder.
The terms "therapeutically effective amount" and "effective amount" can
encompass an
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amount that improves overall therapy, reduces or avoids symptoms or causes of
disease or
disorder, or enhances the therapeutic efficacy of another therapeutic agent.
[0081] As used herein, and unless otherwise specified, a "prophylactically
effective
amount" of a compound is an amount sufficient to prevent a disease or
disorder, or prevent
its recurrence. A prophylactically effective amount of a compound means an
amount of
therapeutic agent, alone or in combination with one or more other agent(s),
which provides
a prophylactic benefit in the prevention of the disease. The term.
"prophylactically effective
amount" can encompass an amount that improves overall prophylaxis or enhances
the
prophylactic efficacy of another prophylactic agent.
[0082] "Tumor," as used herein, refers to all neoplastic cell growth and
proliferation,
whether malignant or benign, and all pre-cancerous and cancerous cells and
tissues.
"Neoplastic," as used herein, refers to any form of dysregulated or
unregulated cell growth,
whether malignant or benign, resulting in abnormal tissue growth. Thus,
"neoplasfic cells"
include malignant and benign cells having dysregulated or unregulated cell
growth.
[0083] The terms "cancer" and "cancerous" refer to or describe the
physiological
condition in mammals that is typically characterized by unregulated cell
growth.. Examples
of cancer include, but are not limited to blood borne (e.g., lymphoma,
leukemia) and solid
tumors.
[0084] As used herein, and unless otherwise specified, the term
"proliferative" disorder
or disease refers to unwanted cell proliferation of one or more subset of
cells in a
multicel.lular organism resulting in harm (i.e., discomfort or decreased life
expectancy) to
the multicellular organism. For example, as used herein, proliferative
disorder or disease
includes neoplasti.c disorders and other proliferative disorders.
[0085] As used herein, and unless otherwise specified, the term "relapsed"
refers to a
situation where a subject, that has had a remission of cancer after a therapy,
has a return of
cancer cells.
[0086] .As used herein, and unless otherwise specified, the term
"refractory" or
"resistant" refers to a circumstance where a subject, even after intensive
treatment, has
residual cancer cells in the body.
[0087] The terms "composition," "formulation," and "dosage form," as used
herein are
intended to encompass compositions comprising the specified ingredient(s) (in
the specified
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amounts, if indicated), as well as any product(s) which result, directly or
indirectly, from
combination of the specified ingredient(s) in the specified amount(s). By
"pharmaceutical"
or "pharmaceutically acceptable" it is meant that any diluent(s), excipient(s)
or carrier(s) in
the composition, formulation, or dosage form are compatible with the other
ingredient(s)
and not deleterious to the recipient thereof. Unless indicated otherwise, the
terms
"composition," "formulation," and "dosage form" are used herein
interchangeably.
[0088] The term "immediate release," when used herein in reference to a
composition,
formulation, or dosage form provided herein, means that the composition,
formulation, or
dosage form does not comprise a component (e.g., a coating) that serves to
delay the spatial
and/or temporal release of some or all of the API from the composition,
formulation, or
dosage form beyond the stomach following oral administration. In certain
embodiments, an
immediate release composition, formulation, or dosage form. is one that
releases the API
substantially in the stomach following oral administration. In specific
embodiments, an
immediate release composition, formulation, or dosage form is one that is not
delayed-
release. In specific embodiments, an immediate release composition,
formulation, or
dosage form is one that does not comprise an enteric coating.
[0089] The terms "non-enteric-coated" and "non-enteric coating," when used
herein,
refers to a pharmaceutical composition, formulation, or dosage form that does
not comprise
a coating intended to release the active ingredient(s) beyond the stomach
(e.g., in the
intestine). In certain embodiments, a non-enteric-coated composition,
formulation, or
dosage form is designed to release the active ingredient(s) substantially in
the stomach.
[0090] The term "substantially in the stomach," when used herein in
reference to a
composition, formulation, or dosage form provided herein, means that at least
about 99%, at
least about 95%, at least about 90%, at least about 85%, at least about 80%,
at least about
75%, at least about 70%, at least about 65%, at least about 60%, at least
about 55%, at least
about 50%, at least about 45%, at least about 40%, at least about 35%, at
least about 30%, at
least about 25%, at least about 20%, at least about 15%, or at least about 10%
of the
cytidine analog is released in the stomach. The term "released in the stomach"
and related
terms as used herein refer to the process whereby the cytidine analog is made
available for
uptake by or transport across cells lining the stomach and then made available
to the body.
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[0091] The term "subject" is defined herein to include animals such as
mammals,
including, but not limited to, primates (e.g., humans), cows, sheep, goats,
horses, dogs, cats,
rabbits, rats, mice and the like. In specific embodiments, the subject is a
human.
[0092] The terms "co-administration" and "in combination with" include the
administration of two or more therapeutic agents either simultaneously,
concurrently or
sequentially within no specific time limits. In one embodiment, the agents are
present in the
cell or in the subject's body at the same time or exert their biological or
therapeutic effect at
the same time. In one embodiment, the therapeutic agents are in the same
composition or
unit dosage form. In other embodiments, th.e therapeutic agents are in
separate
compositions or unit dosage forms. In certain embodiments, a first agent can
be
administered prior to (e.g., 5 minutes, 15 minutes, 30 minutes, 45 minutes, 1
hour, 2 hours,
4 hours, 6 hours, 12 hours, 24 hours, 48 hours, 72 hours, 96 hours, 1 week, 2
weeks, 3
weeks, 4 weeks, 5 weeks, 6 weeks, 8 weeks, or 12 weeks before), concomitantly
with, or
subsequent to (e.g., 5 minutes, 15 minutes, 30 minutes, 45 minutes, 1 hour, 2
hours, 4 hours,
6 hours, 12 hours, 24 hours, 48 hours, 72 hours, 96 hours, 1 week, 2 weeks, 3
weeks, 4
weeks, 5 weeks, 6 weeks, 8 weeks, or 12 weeks after) the administration of a
second
therapeutic agent.
[0093] The term. "solvate" refers to a complex or aggregate formed by one
or more
molecules of a solute, e.g., a compound provided herein, and one or more
molecules of a
solvent, which present in stoichiometric or non-stoichiometric amount.
Suitable solvents
include, but are not limited to, water, methanol, ethanol, n-propanol,
isopropanol, and acetic
acid. In certain embodiments, the solvent is pharmaceutically acceptable. In
one
embodiment, the complex or aggregate is in a crystalline form. In another
embodiment, the
complex or aggregate is in a noncrystalline form. Where the solvent is water,
the solvate is
a hydrate. Examples of hydrates include, but are not limited to, a
hemihydrate,
monohydrate, dihydrate, trihydrate, tetrahydnite, and pentahydrate.
[0094] The term. "isotopic composition" refers to the amount of each
isotope present in
a given atomic position, and "natural isotopic composition" refers to the
naturally occurring
isotopic composition or abundance for a given atomic position. Atomic
positions
containing their natural isotopic composition may also be referred to herein
as "non-
enriched." Unless otherwise designated, the atomic positions of the compounds
recited
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herein are meant to represent any stable isotope of that atom. For example,
unless otherwise
stated, when a position is designated specifically as "H" or "hydrogen," the
position is
understood to have hydrogen at its natural isotopic composition.
[0095] The term "isotopically enriched" refers to an atomic position having
an isotopic
composition other than the natural isotopic composition of that atom.
"Isotopically
enriched" may also refer to a compound containing at least one atomic position
having an
isotopic composition other than the natural isotopic composition of that atom.
As used
herein, an "isotopologue" is an isotopically enriched compound.
[0096] The term. "isotopic enrichment" refers to the percentage of
incorporation of an
amount of a specific isotope at a given atomic position in a molecule in the
place of that
atom's natural isotopic composition. For example, deuterium enrichment of 1%
at a given
position means that 1% of the molecules in a given sample contain deuterium at
the
specified position. Because the naturally occurring distribution of deuterium
is about
0.0156%, deuterium. enrichment at any position in a compound synthesized using
non-
enriched starting materials is about 0.0156%.
[0097] The term "isotopic enrichment factor" refers to the ratio between
the isotopic
composition and the natural isotopic composition of a specified isotope.
[0098] With regard to the compounds provided herein, when a particular
atomic
position is designated as having deuterium or "D," it is understood that the
abundance of
deuterium at that position is substantially greater than the natural abundance
of deuterium,
which is about 0.015%. A position designated as having deuterium typically has
a
minimum isotopic enrichment factor of, in particular embodiments, at least
1000 (15%
deuterium incorporation), at least 2000 (30% deuterium incorporation), at
least 3000 (45%
deuterium incorporation), at least 3500 (52.5% deuterium incorporation), at
least 4000 (60%
deuterium. incorporation), at least 4500 (67.5% deuterium incorporation), at
least 5000 (75%
deuterium incorporation), at least 5500 (82.5% deuterium incorporation), at
least 6000 (90%
deuterium incorporation), at least 6333.3 (95% deuterium incorporation), at
least 6466.7
(97% deuterium incorporation), at least 6600 (99% deuterium incorporation.),
or at least
6633.3 (99.5% deuterium incorporation) at each designated deuterium position.
[0099] The isotopic enrichment and isotopic enrichment factor of the
compounds
provided herein can be determined using conventional analytical methods known
to one of
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ordinary skill in the art, including, e.g., mass spectrometry, nuclear
magnetic resonance
spectroscopy, and crystallography.
B. Cvtidine Analo2s,
1. Overview
[00100] Provided herein are dosage forms, pharmaceutical formulations and
compositions comprising cytidine analogs that release the API substantially in
the stomach
upon oral administration. In certain embodiments, the cytidine analog is 5-
azacytidine. In
certain embodiments, the cytidine analog is 5-aza-2'-deoxycytidine (decitabine
or 5-aza-
CdR). In certain embodiments, the cytidine analog is, for example: 143-D-
arabinofuranosylcytosine (Cytarabine or ara-C); pseudoiso-cytidine (psi ICR);
5-fluoro-2'-
deoxycytidine (FUR); 2'-deoxy-2',2'-difluorocytidine (Gemcitabine); 5-aza-2'-
deoxy-2',2'-
difluorocytidine; 5-aza-2'-deoxy-2'-fluorocytidine; 143-D-ribofuranosyl-2(1.H)-
pyrimidinone
(Zebularine); 2',3'-dideoxy-5-fluoro-3'-thiacytidine (Emtriva); T-
cyclocytidine (Ancitabine);
l-ii-D-arabinofuranosyl-5-azacytosine (Fazarabine or ara-AC); 6-azacytidine (6-
aza-CR);
5,6-dihydro-5-azacytidine (dH-aza-CR); N4-pentyloxy-carbonyl-5'-deoxy-5-
fluorocytidine
(Capeci.tabine); N4-octad.ecyl-cytarabine; elaid.ic acid cytarabi.ne; or a
conjugated compound
comprising a cytidine analog and a fatty acid (e.g., an azacitidine¨fatty acid
conjugate,
including, but not limited to, CP-4200 (Clavis Pharma .AS.A) or a compound
disclosed in
WO 2009/042767, such as aza-C-5'-petroselinic acid ester or aza-C-5'-
petroselaidic acid
ester).
[00101] In certain embodiments, cytidine analogs provided herein include
esterified
derivatives of cytidine analogs, such as, e.g., esterified derivatives of 5-
azacytidine. In
particular embodiments, esterified derivatives are cytidine analogs that
contain an ester
moiety (e.g., an acetyl group) at one or more positions on the cytidine analog
molecule.
Esterified derivatives may be prepared by any method known in the art. In
certain
embodiments, esterified derivatives of a cytidine analog serve as prodrugs of
the cytidine
analog, such that, e.g., following administration of an esterified derivative,
the derivative is
deacetylated in vivo to yield the cytidine analog. A particular embodiment
herein provides
2',3',5'-triacety1-5-azacytidine (TAC), which possesses favorable physical-
chemical and
therapeutic properties. See, e.g., international Publication No. WO
2008/092127
(International Application No. PCT/US2008/052124); Ziemba, A.J., etal.,
"Development of
27
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PCT/US2015/048812
Oral Demethylating Agents for the Treatment of Myelodysplasfic Syndrome"
(Abstract No.
3369), In: Proceedings of the 100th Annual Meeting of the American Association
for
Cancer Research; 2009 Apr. 18-22; Denver, Co. Philadelphia (PA): AACR; 2009
(both of
which are incorporated by reference herein in their entireties).
[00102] In certain embodiments, the cytidine analogs provi.ded herein include
any
compound which is structurally related to cytidine or deoxycytidine and
functionally
mimics and/or antagonizes the action of cytidine or deoxycytidine. Certain
embodiments
herein provide salts, cocrystals, solvates (e.g., hydrates), complexes,
prodrugs, precursors,
m.etabolites, and/or other derivatives of the cytidine analogs provided
herein. For example,
particular embodiments provide salts, cocrystals, solvates (e.g., hydrates),
complexes,
precursors, metabolites, and/or other derivatives of 5-azacytidine. Certain
embodiments
provide cytidine analogs that are not salts, cocrystals, solvates (e.g.,
hydrates), or complexes
of the cytidine analogs provided herein. For example, particular embodiments
provide 5-
azacytidine in a non-ionized, non-solvated (e.g., anhydrous), non-complexed
form. Certain
embodiments herein provide mixtures of two or more cytidine analogs provided
herein.
[00103] Cytidine analogs provided herein may be prepared using synthetic
methods and
procedures referenced herein or otherwise available in the literature. For
example,
particular methods for synthesizing 5-azacytidine are taught in, e.g., U.S.
Patent No.
7,038,038 and references discussed therein, each of which is incorporated
herein by
reference. 5-Azacytidine is also available from Celgene Corporation, Warren,
NJ. Other
cytidine analogs provided herein may be prepared using previously disclosed
synthetic
procedures available to a person of ordinary skill in the art.
[00104] In certain embodiments, exemplary cytidine analogs have the structures
provided
below:
NH2 NH2 NH2 NH2
N N - N N NH
-N 0 N` 0 N '0 0
HO HO.. HO HO
0,P 0
H F H
OH OH OH OH H OH OH
Azacitidine Decitabine Cytarabine (Ara-C)
Pseudoisocytidine (psi 1CR)
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WO 2016/0-10238 PCT/US2015/048812
NH2 NH-)
F N NH2
N
y
.N,==0
N." N N
0
HO HO HONicf5
,o.f HO
H H
OH F OH OH OH HS
Gemcitabirie Zebularine FCdR Emtriva
NH2 NH2
N HN N
0 N 0
HO., HO
o 0
1,1
H H
H OH OH OH
6-Ancytidine 5-6-Dihydro-5-azacytidine
2. Isotopically Enriched Cytidine Analogs
[00105] Particular embodiments herein provide isotopically enriched cytidine
analogs,
prodrugs thereof, synthetic intermediates thereof, and metabolites thereof.
For example,
specific embodiments herein provide isotopically enriched 5-azacytidine.
[00106] Isotopic enrichment (e.g., deuteration) of pharmaceuticals to improve
pharmacokinetics ("PK"), pharmacody-namics ("PD"), and toxicity profiles, has
been
demonstrated previously with some classes of drugs. See, e.g., Lijinsky et.
al., Food
Cosmet. Toxicol., 20: 393 (1982); Lijinsky et. al., J. Nat. Cancer Inst., 69:
1127 (1982);
Mangold et. al., Mutation Res. 308: 33 (1994); Gordon et. al., Drug Metab.
Dispos., 15: 589
(1987); Zello et. al., Metabolism, 43: 487 (1994); Gately et. al., J. Nucl.
Med., 27: 388
(1986); Wade, D., Chem. Biol. Interact. 117: 191 (1999).
[00107] Without being limited by any particular theory, isotopic enrichment of
a drug
can be used, for example, to: (1) reduce or eliminate unwanted metabolites;
(2) increase the
half-life of the parent drug; (3) decrease the number of doses needed to
achieve a desired
effect; (4) decrease the amount of a dose necessary to achieve a desired
effect; (5) increase
the formation of active metabolites, if any are formed; and/or (6) decrease
the production of
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deleterious metabolites in specific tissues and/or create a more effective
drug and/or a safer
drug for combination therapy, whether the combination therapy is intentional
or not.
[00108] Replacement of an atom for one of its isotopes may often result in a
change in
the reaction rate of a chemical reaction. This phenomenon is known as the
Kinetic Isotope
Effect ("KIE"). For example, if a C---H bond is broken during a rate-
determining step in a
chemical reaction (i.e. the step with the highest transition state energy),
substitution of a
deuterium for that hydrogen will cause a decrease in the reaction rate and the
process will
slow down. This phenomenon is known as the Deuterium Kinetic Isotope Effect
("DKIE").
See, e.g, Foster et al., Adv. Drug Res., vol. 14, pp. 1-36 (1985); Kushner et
al., Can. J.
Physiol. Pharmacol., vol. 77, pp. 79-88 (1999).
[00109] The magnitude of the DKIE can be expressed as the ratio between the
rates of a
given reaction in which a C--H bond is broken, and the same reaction where
deuterium is
substituted for hydrogen. The DKIE can range from about 1 (no isotope effect)
to very
large numbers, such as 50 or more, meaning that the reaction can be fifty, or
more, times
slower when deuterium is substituted for hydrogen. Without being limited by a
particular
theory, high DKIE values may be due in part to a phenomenon known as
tunneling, which
is a consequence of the uncertainty principle. Tunneling is ascribed to the
small mass of a
hydrogen atom, and occurs because transition states involving a proton can
sometimes form
in the absence of the required activation energy. Because deuterium has more
mass than
hydrogen, it statistically has a much lower probability of undergoing this
phenomenon.
[00110] Tritium ("T") is a radioactive isotope of hydrogen, used in research,
fusion
reactors, neutron generators and radiopharmaceuticals. Tritium is a hydrogen
atom that has
2 neutrons in the nucleus and has an atomic weight close to 3. It occurs
naturally in the
environment in very low concentrations, most commonly found as T20. Tritium
decays
slowly (half-life = 12.3 years) and emits a low energy beta particle that
cannot penetrate the
outer layer of human skin. Internal exposure is the main hazard associated
with this isotope,
yet it must be ingested in large amounts to pose a significant health risk. As
compared with
deuterium, a lesser amount of tritium must be consumed before it reaches a
hazardous level.
Substitution of tritium ("T") for hydrogen results in yet a stronger bond than
deuterium and
gives numerically larger isotope effects.
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[00111] Similarly, substitution of isotopes for other elements, including, but
not limited
to, 13C or 14C for carbon, 33S, 34S, or 36S for sulfur, 15N for nitrogen, and
170 or 180 for
oxygen, may lead to an analogous kinetic isotope effect.
[00112] The animal body expresses a variety of enzymes for the purpose of
eliminating
foreign substances, such as therapeutic agents, from its circulation system.
Examples of
such enzymes include the cytochrome P450 enzymes ("CYPs"), esterases,
proteases,
reductases, dehydrogenases, and monoamine oxidases, to react with and convert
these
foreign substances to more polar intermediates or metabolites for renal
excretion. Some of
the most common metabolic reactions of pharmaceutical compounds involve the
oxidation
of a carbon-hydrogen (C¨H) bond to either a carbon-oxygen (C-0) or carbon-
carbon (C¨C)
pi-bond. The resultant metabolites may be stable or unstable under
physiological
conditions, and can have substantially different pharmacokinetic,
pharmacodynamic, and
acute and long-term toxicity profiles relative to the parent compounds. For
many drugs,
such oxidations are rapid. As a result, these drugs often require the
administration of
multiple or high daily doses.
[00113] Isotopic enrichment at certain positions of a compound provided herein
may
produce a detectable KIE that affects the pharmacokinetic, pharmacologic,
and/or
toxicological profiles of a compound provided herein in comparison with a
similar
compound having a natural isotopic composition. In one embodiment, the
deuterium
enrichment is performed on the site of C¨H bond cleavage during metabolism.
[00114] Certain embodiments herein provide deuterium enriched 5-azacytidine
analogs,
wherein one or more hydrogen(s) in the 5-azacytidine molecule is/are
isotopically enriched
with deuterium. In certain embodiments, provided herein are compounds of
formula (I):
NH2
NN
7)L
Y' YNO
y4 so,
Y3 Y6
OH OH
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wherein one or more Y atom(s) (i.e., yl, y-2, y-3, y4, -y5, ,-6,
Y and Y7) is/are hydrogen(s)
isotopically enriched with deuterium, and any remaining Y atom(s) is/are non-
enriched
hydrogen atom(s). In particular embodiments, one, two, three, four, five, six,
or seven of
the indicated Y atom(s) is/are isotopically enriched with deuterium, and any
remaining Y
atom(s) is/are non-enriched hydrogen(s).
[00115] In certain embodiments, one or more Y atoms on the ribose moiety of
Compound (1) are deuterium-enriched. Particular examples include, but are not
limited to,
the following compounds, in which the label "D" indicates a deuterium-enriched
atomic
position, i.e., a sample comprising the given compound has a deuterium
enrichment at the
indicated position(s) above the natural abundance of deuterium:
NH2 NH2 NH2
N.-. Ni NN N- '.-N1
11 11
.s.N''0 ILN'Ns'0 .s.N
0
HOõ.v...Ø.... HO., HO
_____....0,õ, ......õ.....- -
....õ,
H H H D D H
H D H 1 H H H
OH OH,OH OH OH OH
, .
I- I 1-2 1-3
NH2 NH2 NH2
,,-L.
N.,'1,--,N
NN N N
L ,L,
N,_
--s0 -,.. 0
D 0
HO HO,õ JD HO D 0,
H Fi ici . 4 D H
D . H H H D H
01-1 OH, , OH OH OH OH
1-4 1-5 1-6
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WO 2016/0-10238 PCT/US2015/048812
NH2
P
HO D i
..-0
D D
D D
,,..s.........
and OH OH .
1-7
[00116] In certain embodiments, the Y atom. on the 5-azacytosine moiety of
Compound
(1) is deuterium-enriched. Particular example includes the following compound,
in which
the label "D" indicates a deuterium-enriched atomic position, Le., a sample
comprising the
given compound has a deuterium enrichment at the indicated position(s) above
the natural
abundance of deuterium:
NH2
N,,k
N
D 0
HO.,,,.
r)
Hc.......le
OH OH .
1-8
[00117] In certain embodiments, one or more Y atoms on the ribose moiety and
the Y
atom on the 5-azacytosine moiety of Compound (I) are deuterium-enriched.
Particular
examples include, but are not limited to, the following compounds, in which
the label "D"
indicates a deuterium-enriched atomic position, i.e., a sample comprising the
given
compound has a deuterium enrichment at the indicated position(s) above the
natural
abundance of deuterium:
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WO 2016/0-10238 PCT/US2015/048812
NH2 NH2 NH2
N...--,NN N NN
I .,......t, ,./..k
..õ1.... .......L.
D....""NN.. N..--=AN'sk.
0 DNO DNO
H 01 tc.... HO HO,,..s.
0 0
Lei...4
H D H H H H
OH OH0 H OH OH OH
, , ,
1-9 1-10 1-11
NH- NH. NH2
./IN.N..s.
N N N ..,""=k...s. N N,-,--LN
D.)N 0 DNO
D D D No
HO HO D
....õ,..- 0 .....,, __,..-0-..,...
H H H H D H
D i H H H D
OH 01-1 OH Old OH OH
,
1-12 1-1.3 1-14
NH2
.,..'",
N = N
I
-,''-`=, ;
D 0
D
HO
..--0.--...,....
D D
D
and OH OH .
1-15
[00118] It is understood that one or more deuterium(s) may exchange with
hydrogen
under physiological conditions.
[00119] Certain embodiments herein provide carbon-13 enriched analogs of 5-
azacytidine, wherein one or more carbon(s) in the 5-azacytidine molecule
is/are isotopically
enriched with carbon-13. In certain embodiments, provided herein are compounds
of
formula (11):
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WO 2016/0-10238 PCT/US2015/048812
NH
i
,A....._
N.--- ===-..;,.._N
I
2
N-, ,.-:=,,
N 0
HO,,.
8
i....,...-0-..,
70õ,r. H---A
. -4-6- 1
Hi 1 H
OH OH
OD,
wherein one or more of 1, 2, 3, 4, 5, 6, 7, or 8 is/are carbon atom(s)
isotopically enriched
with carbon-13, and any remaining atom(s) of 1, 2, 3, 4, 5, 6, 7, or 8 is/are
non-enriched
carbon atom(s). In particular embodiments, one, two, three, four, five, six,
seven, or eight
carbon atom(s) (i.e., atoms 1, 2, 3, 4, 5, 6, 7, and 8) is/are isotopically
enriched with carbon-
13, and any remaining carbon atom(s) is/are non-enriched.
[00120] In certain embodiments, one or more carbon atom(s) of the ribose
moiety of
Compound (II) are enriched with carbon-13. Particular examples include, but
are not
limited to, the following compounds, in which the asterisk ("*") indicates a
carbon-13
enriched atomic position, i.e., a sample comprising the given compotuld has a
carbon-13
enrichment at the indicated position(s) above the natural abundance of carbon-
13:
NH2 NH2 NH2
N,.." N,,N
N
L N/LN.N
L L
N'''' 0
HO HO-N, HO
0
HH - ---1-2-1 -
H H H H H
OH OH OH OH OH OH
, , ,
I I- 1 11-2 11-3
NH NI+, NH2
N.õ--L...,N N,.."LN N.,/-N.,,-,.
N
L
.."-s, =="."'s-,
,..
N Li ,
N 0 N''. '0
HO
' HO
0 *. H ..-0, HO'')Nsi......
1.......õ...-0
* H H H H
OH OH O OH OH OH
= = =
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11-4 11-5 ..11-6
NH NI-1 , NH2
N = N1 N N N
NO.NO ,,=k,
N N-- 0
HO HO HO. *
*
...-- -
, F-I
),
OH OH OH OH, OH OH
1 .
11-7 11-8 11-9
NH2 NH2
...k.. ..--
N N N 'L.
N
V..,,, (:) L. N
/
HO, HO
0 * 0-
* 1-c4-1 * H H *
H H H
OH OH ,and OH OH .
11-10 11-11
[00121] In certain embodiments, one or more carbon atom(s) of the 5-
azacytosin.e moiety
of Compound (H) are enriched with carbon-13. Particular examples include, but
are not
limited to, the following compounds, in which the asterisk "*" indicates a
carbon-13
enriched atomic position, i.e., a sample comprising the given compound has a
carbon-13
enrichment at the indicated position(s) above the natural abundance of carbon-
13:
NH2 NH2 NH2
,).
N N N 'N N
As. õ,L. IL 4}L
* ft-s= 4,=5--..._
0 0
HO.,,.. HO HO.s.,
N.,
0 0 0
Ic...4'1 1-c4 cl .4
H H
OH OH, OH OH , and OH OH .
1.1-12 11-13 11-14
[00122] In certain embodiments, one or more carbon atoms on the ribose moiety
and one
or more carbon atoms on the 5-azacytosine moiety of Compound (11) are enriched
with
36
CA 02960490 2017-03-07
WO 2016/040238 PCT/US2015/048812
carbon-13, i.e., any combination of carbon-13 enrichment for the ribose moiety
and carbon-
13 enrichment for the azacitosine moiety is encompassed herein.
[00123] In certain embodiments, one or more hydrogen(s) is/are enriched with
deuterium(s) and one or more carbon(s) is/are enriched with carbon-13, i.e.,
any
combination of deuterium enrichment and carbon-13 enrichment of 5-azacyti.dine
is
encompassed herein.
3. Synthesis of Isotopically Enriched Cytidine Analogs
[00124] The compounds described herein may be synthesized using any method
known
to one of ordinary skill in the art. For example, particular compounds
described herein are
synthesized using standard synthetic organic chemistry techniques known to
those of
ordinary skill in the art. In some embodiments, known procedures for the
synthesis of 5-
azacytidine are employed, wherein one or more of the reagents, starting
materials,
precursors, or intermediates are replaced by one or more isotopically-enriched
reagents,
starting materials, precursors, or intermediates, including but not limited to
one or more
deuterium-enriched reagents, starting materials, precursors, or intermediates,
and/or one or
more carbon-13-enriched reagents, starting materials, precursors, or
intermediates.
Isotopically enriched reagents, starting materials, precursors, or
intermediates are
commercially available or may be prepared by routine chemical reactions known
to one of
skill in the art. In some embodiments, the routes are based on those disclosed
in U.S. Patent
No. 7,038,038, which is incorporated herein by reference in its entirety.
[00125] In certain embodiments, a suitable isotopically enriched starting
material, such
as a deuterium-enriched ribose, a deuterium-enriched 5-azacytosine, a carbon-
13-enriched
ribose, and/or a carbon-13-enriched 5-azacytosine, may be employed as the
starting material
in the following general scheme to prepare the corresponding deuterium and/or
carbon-13
enriched 5-az.acytidine (See Scheme 1). Following the procedures in U.S.
Patent No.
7,038,038, 5-azacytosine is treated with hexamethyldisilazane (HMDS) to render
a silylated
5-azacytosine. Tetraacetyl-D-ribose is prepared by reacting D-ribose with
sodium. acetate in
acetic anhydride, following the procedures in Brown et al., Biochemical
Preparations, 1955,
4, 70-76. The silylated 5-azacytosine is coupled to tetraacetyl-D-ribose in
the presence of
TMS-triflate, and the resulting protected 5-azacytidine is treated with sodium
methoxi.de in
methanol to yield 5-azacytidine. See U.S. Patent No. 7,038,038.
37
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Scheme 1
HO,. AcO
Na0Ac
,0H Acetic Anhydride
H H 'OAc
OH OH OAc OAc
NHSiMeAcO
OAc is. -
NH2 NHSiMe3 H
N.====-=o
N FIMDS N',N OAc OAc
_____________________________________________________ Ac0
[L, (NH,) S30 0
-. 2 4
OSikle3 H Fi
.S1
H H
0 Otic OAc
DCM
Na()Me
Me0H
NH2
NN
HO
HI IH
OH OH
[00126] in some embodiments, one or more hydrogen positions in the ribose
portion of
5-azacytidine are enriched with deuterium. Such 5-azacytidine analogs may be
prepared
following Scheme 1 from a suitable deuterium-enriched ribose, purchased from a
commercial source or prepared following literature procedures. Specific
examples of
deuterium-enriched ribose starting material include, but are not limited to,
the following
compounds listed in Table 1, which may be converted to the corresponding
deuterium-
enriched 5-azacytidine analogs.
TABLE 1
Starting5-Azacv Udine
Si rad 11 re Source/Reference
Material Product
3S
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HO
0 OH
D-Ribose-l-D H Cambridge Isotope Lab. I-
1
HO
0
trrOH
D-Ribose-2-D Cambridge Isotope Lab. 1-2
OH OH
HO OH
D-Ribose-3-D D H Omicron Biochemicals, Inc.
1-3
OH OH
H
s jsr.0 OH
D-Ribose-4-D Omicron Biochemicals, Inc. 1-4
0
OH OH
HO i)i)
D-Ribose-5,5'- OH
Omicron Biochemicals, Inc. 1-5
D2
OH OH
HO Prepared following the
D-Ribose- OH procedures in 1-6
3,4,5,5'-D4 D J. Am. Chem. Soc. 1996,
H H
118, 7929-7940.
[00127] In other embodiments, the hydrogen position on the 5-azacytosine ring
of 5-
azacytidine is enriched with deuterium. Such 5-azacytidine analog may be
prepared, e.g.,
from deuterated 5-azacytosine following Scheme 1. The deuterated 5-
azacytosi.ne may be
prepared, e.g., from suitable deuterated reagents as shown in Scheme 2. See
e.g.,
Grimdmann et al., Chem. Ber. 1.954, 87, 19-24; Piskala et al., in Zorbach and
Tipson (eds.)
Synthetic Procedures in Nucleic Acid Chemistry, Vol. 1, Wiley Interscience,
New York,
1968, 107-108; Piskala, Collect. Czech. Chem. Comm. 1967, 32, 3966-3976.
Scheme 2
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NH2
HCI DC(OCH2CH3)3
HN
y Me0H HNyN NH2 (from CiD/N Isotopes)
==================
dry DMF
NH2 NH2 0
(from Aldrich)
Alternative conditions for preparing 5-azacytosine:
0
D/11 NH2
\NH2
HNyNyNH2 (from Aldrich) N/LN
NH2
DMF
0
0
NH2
VINOCH2CH3
NH2 (from Aldrich)
YNa0Et, Et0H o
NH2 0
[00128] In other embodiments, both the hydrogen position on the 5-azacytosine
ring and
one or more hydrogen positions in the ribose portion of 5-azacytidine are
enriched with
deuterium. Such 5-azacytidi.ne analogs may be prepared, e.g., following
Schem.e 1,
coupling a suitable deuterated ribose starting materials with deuterated 5-
azacytosine. For
example, compounds 1-9, 1-10, 1-11, 1-12, 1-13, and 1-14 may be prepared from
the
corresponding deuterated ribose starting material listed in Table 1, and
deuterated 5-
azacytosine prepared according to Schem.e 2.
[00129] In some embodiments, one or more carbon atoms in the ribose portion of
5-
azacytidine are enriched with carbon-1.3. Such 5-azacytidine analogs may be
prepared
following Scheme 1 from a suitable carbon-13-enriched ribose, purchased from a
commercial source or prepared following literature procedures. Specific
examples of
carbon-13-enriched ribose starting material include, but are not li.m.ited to,
the following
compounds listed in Table 2, which may be converted to the corresponding
carbon-13-
enriched 5-azacytidine analogs. (The asterisk "f" indicates a carbon-13
enriched atomic
position)
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TABLE 2
Starting 5-
Azacvtidine
Structure Source/Reference
Material Product
Ho
......).....
D-Ribose- I 1 -13C H H?" OH Sigma Aldrich
II-1
H
H H
HO
s,
D-Ribose-2-13C.......),1 AAP OH Sigma Aldrich 11-2
H
OH OH
HO
D-Ribose-3-13C H H OH Omicron Biochemicals, Inc. 11-3
hi
OH OH
HO
= N-.
0
D-Ribose-4-13C 16 1.1 H OH Omicron Biochemicals, Inc. 11-4
H
OH OH
HO
D-Ribose-5-13C Cambridge Isotope Lab. 11-5
h OH
*"."""""rHH H
HO
D-Ribose- %Niluv.
Sigma Aldrich 11-6
1,2-13C2 H *
OH H
HO
=N,
D-Ribose-
H -) H *OH Omicron Biochemicals, Inc. 11-7
1,3)3C2 H *
OH OH
HO
D-Ribose-
1,5-I3C2 H * 1_, H' OH
Omicron Biochemicals, Inc. 11-8
H
O
HO
= N% .
0
D-Ribose- H H OH
Omicron Biochemicals, Inc. 11-9
2,5-13C2 H *
OH OH
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HO=,...
D-Ribose-
2,3,4,5-13C4 o
* ....... 14ivu-OH Sigma Aldrich II-10
H * *
OH OH
HO,
--..
D-Ribose-
1,2,3,4,5-13C5 o
*
...... 4*.woi-i Cambridge Isotope Lab. II-11
H * *
OH OH
[00130] In other embodiments, one or more carbon atoms in the 5-azacytosine
ring are
enriched with carbon-13. Such 5-azacytidine analogs may be prepared from a
carbon-13-
enriched 5-azacytosine following Schem.e 1. The carbon-13 enriched 5-
azacytosin.e
intermediates may be prepared from suitable carbon-13 enriched reagents as
shown in
Scheme 3. See e.g., Gmndm.ann. et A, Chem. Ber. 1954, 87, 19-24; Piskala
etal., in
Zorbach and Tipson (eds.) Synthetic Procedures in Nucleic Acid Chemistry, Vol.
1, Wiley
Interscience, New York, 1968, 107-108; Piskala, Collect. Czech. Chem. Comm.
1967, 32,
3966-3976.
Scheme 3
NH2
H HC1 H HI3C(OCH2CH3)3 ..õ.-sõ,
N N
MeOli HN,...,4..eõ-N,,.,NH2 (from Sigma Aldrich)
----4". 11-12
* L..... .......L. .......ii...
dry DMF
NH2 NH2 0 N
H 0
from Signa Aldrich)
NI-12
H 11C1 H HC(0CII2C I-13 )3
HNõ. ,N, N ' N
13c- 13,..... Me0ii HN ..,..,Ns.õ..N T NH2 (from Sigma Aldrich)
I k"" *
dry DMF _____________________________________ 0.
is *L ¨.2,11-13
NH2 NH2 0
VI .---0
(from Signa Aldrich)
NH2
H HC1 H HI3C(OCH2CH03 SA_
H N . _,N ,
HN =,..,......,N * NH2 (from Sigma Aldrich) . NLI -N. N
µ13C" 13CN Me H _____________ i A --P- j,.. 11-14
I .,- *
dry DMF *
NH2 NH2 0 N 0
H
(from Siam Aldrich)
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[00131] In other embodiments, one or more carbon positions on the 5-
azacytosine ring
and one or more carbon positions in the ribose portion of 5-azacyfidine are
enriched with
carbon-13. Such 5-azacytidine analogs may be prepared following Scheme 1,
coupling a
suitable carbon-13-enriched ribose starting materials with a suitable carbon-
13-enriched 5-
azacytosine. For example, compounds may be prepared from a carbon-13-enriched
ribose
starting material listed in Table 2, and carbon-13-enriched 5-azacytosine
prepared according
to Scheme 3.
[00132] The routes and methods described above may be modified to provide an
isotopolougue of 5-azacytidine having both deuterium enrichment and carbon-13
enrichment.
C. Pharmaceutical Formulations
I. Overview
[00133] Embodiments herein encompass pharmaceutical formulations and
compositions
comprising one or more cytidine analogs, e.g., 5-azacytidine, and optionally a
permeation
enhancer, wherein the formulations and compositions are prepared for oral
administration.
In a particular embodiment, the formulations and compositions are prepared for
release of
the cytidine analog substantially in the stomach. In specific embodiments, the
cytidine
analogs, e.g., 5-azacytidine, and the pharmaceutical formulations and
compositions are used
for treating diseases and disorders associated with abnormal cell
proliferation, wherein the
cytidine analogs, the formulations and compositions are prepared for oral
administration,
preferably for release of the cytidine analogs substantially in the stomach.
Particular
embodiments relate to the use of one or more cytidine analogs, e.g., 5-
azacytidine, for the
preparation of pharmaceutical formulations and compositions for treating
particular medical
indications, as provided herein. The pharmaceutical formulations and
compositions
comprising cytidine analogs provided herein are intended for oral delivery of
the cytidine
analog in subjects in need thereof. Oral delivery formats include, but are not
limited to,
tablets, capsules, caplets, solutions, suspensions, and syrups, and may also
comprise a
plurality of granules, beads, powders or pellets that may or may not be
encapsulated. Such
formats may also be referred to herein as the "drug core" which contains the
cytidine
analog.
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[00134] Particular embodiments herein provide solid oral dosage forms that are
tablets or
capsules. In certain embodiments, the formulation is a tablet comprising a
cytidine analog.
In certain embodiments, the formulation is a capsule comprising a cytidine
analog. In
certain embodiments, the tablets or capsules provided herein optionally
comprise one or
more excipients, such as, for example, gli.dants, diluents, lubricants,
colorants, disintegrants,
granulating agents, binding agents, polymers, and coating agents. In certain
embodiments,
the formulation is an immediate release tablet. In certain embodiments, the
formulation is a
controlled release tablet releasing the API, e.g., substantially in the
stomach. In certain
embodiments, the formulation is a hard gelatin capsule. In certain
embodiments, the
formulation is a soft gelatin capsule. In certain embodiments, the capsule is
a
hydroxypropyl methylcellulose (HPMC) capsule. In certain embodiments, the
formulation
is an immediate release capsule. in certain embodiments, the formulation is an
immediate
or controlled release capsule releasing the API, e.g., substantially in the
stomach. In certain
embodiments, the formulation is a rapidly disintegrating tablet that dissolves
substantially in
the mouth following administration. In certain embodiments, embodiments herein
encompass the use of cytidine analogs, e.g., 5-azacyfidine, for the
preparation of a
pharmaceutical composition for treating a disease associated with abnormal
cell
proliferation, wherein the composition is prepared for oral administration.
2. Performance of Certain Dosage Forms Provided Herein
[00135] In certain embodiments, the formulations comprising the cytidine
analogs, such
as, for example, 5-azacytidin.e, effect an immediate release of the API upon
oral
administration. In particular embodiments, the formulations comprising the
cytidine
analogs, such as, for example, 5-azacytidine, comprise a therapeutically or
prophylactically
effective amount of the cytidine analog (and, optionally, one or more
excipients) and effect
an immediate release of the API upon oral administration.
[00136] In certain embodiments, the formulations comprising the cytidine
analogs, such
as, for example, 5-azacytidine, effect a controlled release of the API
substantially in the
stomach upon oral administration. In certain embodiments, the formulations
comprising the
cytidine analogs, such as, for example, 5-azacyfidine, comprise a
therapeutically or
prophylactically effective amount of the cytidine analog and a drug release
controlling
component which is capable of releasing the cytidine analog substantially in
the stomach.
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In certain embodiments, matrices (e.g., polymer matrices) may be employed in
the
formulation to control the release of the cytidine analog. In certain
embodiments, coatings
and/or shells may be employed in the formulation to control the release of the
cytidine
analog in the substantially in the stomach.
[00137] In certain embodiments, the formulations comprising the cytidine
analogs, such
as, for example, 5-azacytidine, release the API substantially in the stomach
upon oral
administration. In certain embodiments, the formulations effect an immediate
release of the
cytidine analog upon oral administration. In certain embodiments, the
formulations
optionally further comprises a drug release controlling component, wherein the
drug release
controlling component is adjusted such that the release of the cytidine analog
occurs
substantially in the stomach. In particular embodiments, the drug release
controlling
component is adjusted such that the release of the cytidine analog is
immediate and occurs
substantially in the stomach. In particular embodiments, the drug release
controlling
component is adjusted such that the release of the cytidine analog is
sustained and occurs
substantially in the stomach. In certain embodiments, the formulation of the
cytidine
analog, such as, for example, 5-azacytidine, releases the API substantially in
the stomach,
and, subsequently, releases the remainder of the API in the intestine upon
oral
administration.
[00138] Methods by which skilled practitioners can assess where a drug is
released in the
gastrointestinal tract of a subject are knovvn in the art, and include, for
example,
scintigraphic studies, testing in a bio-relevant medium which simulates the
fluid in relevant
portions of the gastrointestinal tract, among other methods.
[00139] Particular embodiments herein provide pharmaceutical formulations
(e.g.,
immediate release oral formulations and/or formulations that release the API
substantially in
the stomach) comprising a cytidine analog (e.g., 5-azacytidine) that achieve a
particular
exposure in the subject to which the formulation is orally administered, as
compared to a SC
dose of the same cytidine analog. Particular embodiments provide oral
formulations that
achieve an exposure of at least about 5%, at least about 10%, at least about
15%, at least
about 20%, at least about 25%, at least about 30%, at least about 35%, at
least about 40%, at
least about 45%, at least about 50%, at least about 55%, at least about 60%,
at least about
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65%, at least about 70%, at least about 75%, at least about 80%, at least
about 85%, at least
about 90%, at least about 95%, or about 100%, as compared to a SC dose.
[00140] In certain embodiments, the formulation (e.g., immediate release oral
formulation and/or formulation that release the API substantially in the
stomach)
comprising the cytidine analog, such as, for example, 5-azacytidine, renders a
certain
percentage of the cytidine analog in the formulation systemically bioavailable
upon oral
administration. In certain embodiments, after the subject is orally
administered the
formulation, the cytidine analog in the formulation is absorbed substantially
in the stomach,
and becomes available to the body through systemic exposure. In particular
embodiments,
the oral bioavailability of a formulation comprising a cytidine analog
provided herein is,
e.g., greater than about 1%, greater than about 5%, greater than about 10%,
greater than
about 15%, greater than about 20%, greater than about 25%, greater than about
30%, greater
than about 35%, greater than about 40%, greater than about 45%, greater than
about 50%,
greater than about 55%, greater than about 60%, greater than about 65%,
greater than about
70%, greater than about 75%, greater than about 80%, greater than about 85%,
greater than
about 90%, greater than about 95%, or about 100%, of the total amount of the
cytidine
analog in the formulation.
[00141] Methods by which skilled practitioners can assess the oral
bioavailability of a
drug formulation in a subject are known in the art. Such methods, include, for
example,
comparing certain dosing-related parameters, such as, but not limited to,
maximum plasma
concentration ("Cmax"), time to maximum plasma concentration ("i'max"), or
area-under-
the-curve ("AUC") determinations.
[00142] Particular embodiments herein provide pharmaceutical formulations
(e.g.,
immediate release oral formulations and/or formulations that release the API
substantially in
the stomach) comprising a cytidine analog (e.g., 5-azacytidine) that achieve a
particular
AUC value (e.g., AUC(0-t) or AUC(0-x)) in the subject (e.g., human) to which
the
formulation is orally administered. Particular embodiments provide oral
formulations that
achieve an AUC value of at least about 25 ng-hr/mL, at least about 50 ng-
hr/mL, at least
about 75 ng-hr/mL, at least about 100 ng-hr/mL, at least about 150 ng-hr/mL,
at least about
200 ng-hr/mL, at least about 250 ng-hr/mL, at least about 300 ng-hr/mL, at
least about 350
ng-hr/mL, at least about 400 ng-hr/mL, at least about 450 ng-hr/mL, at least
about 500 ng-
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hernL, at least about 550 ng-luirnL, at least about 600 ng-hr/mL, at least
about 650 ng-
hr/mL, at least about 700 ng-hr/mL, at least about 750 ng-hr/mL, at least
about 800 ng-
hr/mL, at least about 850 ng-hr/mL, at least about 900 ng-hr/mL, at least
about 950 ng-
hr/mL, at least about 1000 ng-hr/mL, at least about 1100 ng-hr/mL, at least
about 1200 ng-
hr/mt, at least about 1300 ng-hr/mL, at least about 1400 ng-hr/mL, at least
about 1500 ng-
hr/mL, at least about 1600 ng-hr/mL, at least about 1700 ng-hr/mL, at least
about 1800 ng-
hr/mL, at least about 1900 ng-hr/mL, at least about 2000 ng-hr/mLõ at least
about 2250 ng-
hernL, or at least about 2500 ng-hernL. In particular embodiments, the AUC
determination
is obtained from. a time-concentration ph.armacokinetic profile obtained from
the blood
samples of animals or human volunteers following dosing.
[00143] Particular embodiments herein provide pharmaceutical formulations
(e.g.,
immediate release oral form.ulations and/or formulations that release the API
substantially in
the stomach) comprising a cytidine analog (e.g., 5-azacytidine) that achieve a
particular
maximum plasma concentration ("Cmax") in the subject to which the formulation
is orally
administered. Particular embodiments provide oral formulations that achieve a
Cmax of the
cytidine analog of at least about 25 ng/mL, at least about 50 ng/mL, at least
about 75
ng/mL, at least about 100 ng/mL, at least about 150 ng/mL, at least about 200
ng/mL, at
least about 250 ng/mL, at least about 300 n.g/m1õ at least about 350 ng/mL, at
least about
400 ng/mL, at least about 450 ng/mL, at least about 500 ng/mL, at least about
550 ng/mL, at
least about 600 ng/mL, at least about 650 ng/mL, at least about 700 ng/mL, at
least about
750 ng/mL, at least about 800 ng/mL, at least about 850 ng/mL, at least about
900 ng/mL, at
least about 950 ng/mL, at least about 1000 ng/mL, at least about 1100 ng/mL,
at least about
1200 ng/mL, at least about 1300 ng/mL, at least about 1400 ng/mt, at least
about 1500
ng/mL, at least about 1600 ng/mL, at least about 1700 ng/mL, at least about
1800 ng/mL, at
least about 1900 ng/mL, at least about 2000 ng/mL, at least about 2250 ng/mL,
or at least
about 2500 ng/mL.
[00144] Particular embodiments herein provide pharmaceutical formulations
(e.g.,
immediate release oral formulations and/or formulations that release the API
substantially in
the stomach) comprising a cytidine analog (e.g., 5-azacytidine) that achieve a
particular
ti.m.e to maximum plasma concentration ("r.õ-) in the subject to which the
formulation is
orally administered. Particular embodiments provide oral formulations that
achieve a Tmax
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CA 02960490 2017-03-07
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of the cytidine analog of less than about 10 min., less than about 15 min.,
less than about 20
min., less than about 25 mm., less than about 30 min., less than about 35
min., less than
about 40 min., less than about 45 min., less than about 50 min., less than
about 55 min., less
than about 60 min., less than about 65 min., less than about 70 mm., less than
about 75 mm.,
less than about 80 min., less than about 85 min., less than about 90 min.,
less than about 95
mm., less than about 100 mm., less than about 105 min., less than about 110
min., less than
about 115 min., less than about 120 min., less than about 130 min., less than
about 140
mm., less than about 150 mm., less than about 160 mm., less than about 170
mm., less than
about 180 mm., less than about 190 mm., less than about 200 min., less than
about 210
min., less than about 220 min., less than about 230 min., or less than about
240 min. In
particular embodiments, the T. value is measured from the time at which the
formulation
is orally administered.
[00145] Particular embodiments herein provide oral dosage forms comprising a
cytidine
analog, wherein the oral dosage forms have an enteric coating. Particular
embodiments
provide a permeable or partly permeable (e.g., "leaky") enteric coating with
pores. In
particular embodiments, the permeable or partly permeable enteric-coated
tablet releases the
5-azacytidine in an immediate release manner substantially in the stomach.
3. Design of Certain Dosage Forms Provided Herein
[00146] Provided herein are dosage forms designed to maximize the absorption
and/or
efficacious delivery of certain cytidine analogs, e.g., 5-azacytidine, upon
oral
administration, e.g., for release substantially in the stomach. Accordingly,
certain
embodiments herein provide a solid oral dosage form of a cytidine analog, such
as, for
example, 5-azacytidine, using pharmaceutical excipients designed for immediate
release of
the API upon oral administration, e.g., substantially in the stomach.
Particular immediate
release formulations comprise a specific amount of a cytidine analog and
optionally one or
more excipients. In certain embodiments, the formulation may be an immediate
release
tablet or an immediate release capsule (such as, e.g., an HPMC capsule).
[00147] Provided herein are methods of making the formulations provided herein
comprising the cytidine analogs provided herein (e.g., immediate release oral
formulations
and/or formulations that release the API substantially in the stomach). In
particular
embodiments, the formulations provided herein may be prepared using
conventional
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methods known to those skilled in the field of pharmaceutical formulation, as
described,
e.g., in pertinent textbooks. See, e.g., REMINGTON, THE. SCIENCE AND PRACTICE
OF
PHARMACY, 20th Edition, Lippincott Williams & Wilkins, (2000); ANSEL et al.,
PHARMACEUTICAL DOSAGE FORMS AND DRUG DELIVERY SYSTEMS, 7th Edition, Lippincott
Williams & Wilkins, (1999); GIBSON, PHARMACEUTICAL PREFORMULATION AND
FORMULATION, CRC Press (2001).
[00148] In particular embodiments, formulations provided herein (e.g.,
immediate release
oral formulations, formulations that release the API substantially in the
stomach, or rapidly
disintegrating formulations that dissolve substantially in the mouth) comprise
a cytidine
analog, such as, for example, 5-azacytidine, in a specific amount. In
particular
embodiments, the specific amount of the cytidine analog in the formulation is,
e.g., about 10
mg, about 20 mg, about 40 mg, about 60 mg, about 80 mg, about 100 mg, about
120 mg,
about 140 mg, about 160 mg, about 180 mg, about 200 mg, about 220 mg, least
about 240
mg, about 260 mg, about 280 mg, about 300 mg, about 320 mg, about 340 mg,
about 360
mg, about 380 mg, about 400 mg, about 420 mg, about 440 mg, about 460 mg,
about 480
mg, about 500 mg, about 600 mg, about 700 mg, about 800 mg, about 900 mg,
about 1000
mg, about 1100 mg, about 1200 mg, about 1300 mg, about 1400 mg, about 1500 mg,
about
1600 mg, about 1700 mg, about 1800 mg, about 1900 mg, about 2000 mg, about
2100 mg,
about 2200 mg, about 2300 mg, about 2400 mg, about 2500 mg, about 3000 mg,
about 4000
mg, or about 5000 mg. In particular embodiments, the specific amount of the
cytidine
analog in the formulation is, e.g., at least about 10 mg, at least about 20
mg, at least about
40 mg, at least about 60 mg, at least about 80 mg, at least about 100 mg, at
least about 120
mg, at least about 140 mg, at least about 160 mg, at least about 180 mg, at
least about 200
mg, at least about 220 mg, at least about 240 mg, at least about 260 mg, at
least about 280
mg, at least about 300 mg, at least about 320 mg, at least about 340 mg, at
least about 360
mg, at least about 380 mg, at least about 400 mg, at least about 420 mg, at
least about 440
mg, at least about 460 mg, at least about 480 mg, at least about 500 mg, at
least about 600
mg, at least about 700 mg, at least about 800 mg, at least about 900 mg, at
least about 1000
mg, at least about 1100 mg, at least about 1200 mg, at least about 1300 mg, at
least about
1400 mg, at least about 1500 mg, at least about 1600 mg, at least about 1700
mg, at least
about 1800 mg, at least about 1900 mg, at least about 2000 mg, at least about
2100 mg, at
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least about 2200 mg, at least about 2300 mg, at least about 2400 mg, at least
about 2500 mg,
at least about 3000 mg, at least about 4000 mg, or at least about 5000 mg.
[00149] In certain embodiments, the formulation is a tablet, wherein the
tablet is
manufactured using standard, art-recognized tablet processing procedures and
equipment.
In certain embodiments, the method for forming the tablets is direct
compression of a
powdered, crystalline and/or granular composition comprising the cytidine
analog, alone or
in combination with one or more excipients, such as, for example, carriers,
additives,
polymers, or the like. In certain embodiments, as an alternative to direct
compression, the
tablets may be prepared using wet granulation or dry granulation processes. In
certain
embodiments, the tablets are molded rather than compressed, starting with a
moist or
otherwise tractable material. In certain embodiments, compression and
granulation
techniques are used.
[00150] In certain embodiments, the formulation is a capsule, wherein the
capsules may
be manufactured using standard, art-recognized capsule processing procedures
and
equipments. In certain embodiments, soft gelatin capsules may be prepared in
which the
capsules contain a mixture of the cytidine analog and vegetable oil or non-
aqueous, water
miscible materials such as, for example, polyethylene glycol and the like. In
certain
embodiments, hard gelatin capsules may be prepared containing granules of the
cytidine
analog in combination with a solid pulverulent carrier, such as, for example,
lactose,
saccharose, sorbitol, mannitol, potato starch, corn starch, amylopectin,
cellulose derivatives,
or gelatin. In certain embodiments, a hard gelatin capsule shell may be
prepared from a
capsule composition comprising gelatin and a small amount of plasticizer such
as glycerol.
In certain embodiments, as an alternative to gelatin, the capsule shell may be
made of a
carbohydrate material. In certain embodiments, the capsule composition may
additionally
include polymers, colorings, flavorings and opacifiers as required. In certain
embodiments,
the capsule comprises HPMC.
[00151] In certain embodiments, the formulation of the cytidine analog, such
as, for
example, 5-azacytidine, is prepared using aqueous solvents without causing
significant
hydrolytic degradation of the cytidine analog. In particular embodiments, the
formulation
of the cytidine analog, such as, for example, 5-azacytidine, is a tablet which
contains a
coating applied to the drug core using aqueous solvents without causing
significant
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hydrolytic degradation of the cytidine analog in the formulation. In certain
embodiments,
water is employed as the solvent for coating the drug core. In certain
embodiments, the oral
dosage form of the cytidine analog is a tablet containing a film coat applied
to the drug core
using aqueous solvents. In particular embodiments, water is employed as the
solvent for
film-coating. In particular embodiments, the tablet containing the cytidine
analog is film-
coated using aqueous solvents without effecting degradation of the
pharmaceutical
composition. In particular embodiments, water is used as the film coating
solvent without
effecting degradation of the pharmaceutical composition. In certain
embodiments, an oral
dosage form comprising 5-azacytidine and an aqueous film coating effects
immediate drug
release upon oral delivery. In certain embodiments, the oral dosage form
comprising 5-
azacytidine and an aqueous film coating effects controlled drug release to the
upper
gastrointestinal tract, e.g., the stomach, upon oral administration. in
particular
embodiments, a tablet with an aqueous-based film coating comprises 5-
azacridine as the
API.
[00152] In certain embodiments, provided herein is a controlled release
pharmaceutical
formulation for oral administration of a cytidine analog that releases the
cytidine analog
substantially in the stomach, comprising: a) a specific amount of a cytidine
analog; b) a
drug release controlling component for controlling th.e release of the
cytidine analog
substantially in the upper gastrointestinal tract, e.g., the stomach; and c)
optionally one or
more excipients. In certain embodiments, the oral dosage form comprising the
cytidine
analog is prepared as a controlled release tablet or capsule which includes a
drug core
comprising the pharmaceutical composition and optional excipients. Optionally,
a "seal
coat" or "shell" is applied. In certain embodiments, a formulation provi.ded
herein
comprising a cytidine analog provided herein is a controlled release tablet or
capsule, which
comprises a therapeutically effective amount of the cytidine analog, a drug
release
controlling component that controls the release of the cytidine analog
substantially in the
stomach upon oral administration, and optionally, one or more excipients.
[00153] Particular embodiments provide a drug release controlling component
that is a
polymer matrix, which swells upon exposure to gastric fluid to effect the
gastric retention of
the formulation and the sustained release of the cytidine analog from the
polymer matrix
substantially in the stomach. In certain embodiments, such formulations may be
prepared
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by incorporating the cytidine analog into a suitable polymeric matrix during
formulation.
Examples of such formulations are known in the art. See, e.g., Shell et al.,
U.S. Patent
Publication No. 2002/0051820 (Application No. 09/990,061); Shell etal., U.S.
Patent
Publication No. 2003/0039688 (Application No. 10/045,823); Gusler etal., U.S.
Patent
Publication No. 2003/0104053 (Application No. 10/029,134), each of which is
incorporated
herein by reference in its entirety.
[00154] In certain embodiments, the drug release controlling component may
comprise a
shell surrounding the drug-containing core, wherein the shell releases the
cytidine analog
from the core by, e.g., permitting diffusion of the cytidine analog from the
core and
promoting gastric retention of the formulation by swelling upon exposure to
gastric fluids to
a size that is retained in the stomach. In certain embodiments, such
formulations may be
prepared by first compressing a mixture of the cytidine analog and one or more
excipients to
form a drug core, and compressing another powdered mixture over the drug core
to form the
shell, or enclosing the drug core with a capsule shell made of suitable
materials. Examples
of such formulations are known in the art. See, e.g., Berner etal., U.S.
Patent Publication
No. 2003/0104062 Application No. 10/213,823), incorporated herein by reference
in its
entirety.
[00155] Certain embodiments herein provide oral dosage forms comprising a
cytidine
analog, wherein the dosage form contains pores in the conventional enteric
coating. In
particular embodiments, the oral dosage form of the cytidine analog is a
tablet that contains
a permeable or partly permeable (e.g., "leaky") enteric coating with pores. In
particular
embodiments, the permeable or partly permeable enteric-coated tablet controls
the release
of the cytidine analog from the tablet primarily to the upper gastrointestinal
tract, e.g., the
stomach. In particular embodiments, the permeable or partly permeable enteric-
coated
tablet comprises 5-azacytidine. In particular embodiments, the remainder of
the cytidine
analog is subsequently released beyond the stomach (e.g., in the intestine).
[00156] In certain embodiments, the pharmaceutical formulation provided herein
is a
compressed tablet comprising a cytidine analog. In addition to the cytidine
analog, the
tablet optionally comprises one or more excipients, including (a) diluents or
fillers, which
may add necessary bulk to a formulation to prepare tablets of the desired
size; (b) binders or
adhesives, which may promote adhesion of the particles of the formulation,
enabling a
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granulation to be prepared and maintaining the integrity of the final tablet;
(c) disintegrants
or disintegrating agents, which, after administration, may promote breakup of
the tablets to
smaller particles for improved drug availability; (d) anti-adherents,
gli.dants, lubricants or
lubricating agents, which may enhance flow of the tableting material into the
tablet dies,
minimize wear of the punches and dies, prevent the sticking of fil l material
to the punches
and dies, and produce tablets having a sheen; and (e) miscellaneous adjuncts
such as
colorants and flavorants. After compression, tablets provided herein may be
coated with
various materials as described herein.
[00157] In certain embodiments, the pharmaceutical formulation provided herein
is a
multiple compressed tablet of a cytidine analog. Multiple compressed tablets
are prepared
by subjecting the fill material to more than a single compression. The result
may be a
multiple-layered tablet or a tablet-within-a-tablet, the inner tablet being
the core comprising
a cytidine analog and optionally one or more excipients, and the outer portion
being the
shell, wherein the shell comprises one or more excipients, and may or may not
contain the
cytidine analog. Layered tablets may be prepared by the initial compaction of
a portion of
fill material in a die followed by additional fill material and compression to
form two- or
three-layered tablets, depending upon the number of separate fills. Each layer
may contain
a different therapeutic agent, separate from one another for reasons of
chemical or physical
incompatibility, or the same therapeutic agent for staged drug release, or
simply for the
unique appearance of the multiple-layered tablet. Each portion of fill may be
colored
differently to prepare a distinctive looking tablet. In the preparation of
tablets having a
compressed tablet as the inner core, special machines may be used to place the
preformed
tablet precisely within the die for the subsequent compression of surrounding
fill material.
[00158] In certain embodiments, the compressed tablet of a cytidine analog may
be
coated with a colored or an uncolored sugar layer. The coating m.ay be water-
soluble and
quickly dissolved after oral ingestion. The sugar coating may serve the
purpose of
protecting the enclosed drug from the environment and providing a barrier to
an
objectionable taste or smell. The sugar coating may also enhance the
appearance of the
compressed tablet and permit the imprinting of identifying manufacturer's
information. In
certain embodiments, sugar-coated tablets may be 50% larger and heavier than
the original
uncoated tablets. The sugar-coating of tablets may be divided into the
following optional
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steps: (1) waterproofing and sealing (if needed); (2) sub-coating; (3)
smoothing and final
rounding; (4) finishing and coloring (if desired); (5) imprinting (if needed);
and (6)
polishing.
[00159] In certain embodiments, the compressed tablet of a cytidine analog may
be film-
coated. Film-coated tablets may be compressed tablets coated with a thin layer
of a
polymer capable of forming a skin-like film over the tablet. The film is
usually colored and
has the advantage to be more durable, less bulky, and less time-consuming to
apply. By its
composition, the coating may be designed to rupture and expose the core tablet
at the
desired location within the gastrointestinal tract. The film-coating process,
which places a
thin skin-tight coating of a plastic-like material over the compressed tablet,
may produce
coated tablets having essentially the same weight, shape, and size as the
originally
compressed tablet. The film-coating may be colored to make the tablets
attractive and
distinctive. Film-coating solutions may be non-aqueous or aqueous. In
particular
embodiments, the non-aqueous solutions may optionally contain one or more of
the
following types of materials to provide the desired coating to the tablets:
(1) a film former
capable of producing smooth, thin films reproducible under conventional
coating conditions
and applicable to a variety of tablet shapes, such as, for example, cellulose
acetate phthalate;
(2) an alloying substance providing water solubility or permeability to the
film to ensure
penetration by body fluids and therapeutic availability of the drug, such as,
for example,
polyethylene glycol; (3) a plasticizer to produce flexibility and elasticity
of the coating and
thus provide durability, such as, for example, castor oil; (4) a surfactant to
enhance
spreadability of the film during application, such as, for example,
polyoxyethylene sorbitan
derivatives; (5) opaquants and colorants to make the appearance of the coated
tablets
attractive and distinctive, such as, for example, titanium dioxide as an
opaquant, and FD&C
or D&C dyes as a colorant; (6) sweeteners, flavors, or aromas to enhance the
acceptability
of the tablet to the subject, such as, for example, saccharin as sweeteners,
and vanillin as
flavors and aromas; (7) a glossant to provide a luster to the tablets without
a separate
polishing operation, such as, for example, beeswax; and (8) a volatile solvent
to allow the
spread of the other components over the tablets while allowing rapid
evaporation to permit
an effective yet speedy operation, such as, for example, alcohol-acetone
mixture. In certain
embodiments, an aqueous film-coating formulation may contain one or more of
the
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following: (1) film-forming polymer, such as, for example, cellulose ether
polymers as
hydroxypropyl methyl-cellulose, hydroxypropyl cellulose, and methyl-cellulose;
(2)
plasticizer, such as, for example, glycerin, propylene glycol, polyethylene
glycol, diethyl
phthalate, and dibutyl subacetate; (3) colorant and pacifier, such as, for
example, FD&C or
D&C lakes and iron oxide pigments; or (4) vehicle, such as, for example,
water.
[00160] In certain embodiments, the compressed tablet of a cytidine analog may
be
compression-coated. The coating material, in the form of a granulation or
powder, may be
compressed onto a tablet core of drug with a special tablet press.
[00161] In certain embodiments, the pharmaceutical formulation is a gelatin-
coated tablet
of a cytidine analog. A gelatin-coated tablet is a capsule-shaped compressed
tablet that
allows the coated product to be smaller than a capsule filled with an
equivalent amount of
powder. The gelatin coating facilitates swallowing and compared to unsealed
capsules,
gelatin-coated tablets may be more tamper-evident.
[00162] In certain embodiments, the pharmaceutical formulation may be a
sublingual
tablet of a cytidine analog. The sublingual tablet is intended to be dissolved
beneath the
tongue for absorption through the oral mucosa. The sublingual tablet may
dissolve
promptly and provide rapid release of the drug.
[00163] In certain embodiments, the pharmaceutical formulation is an immediate
release
tablet of a cytidine analog. In certain embodiments, the immediate release
tablet is
designed, e.g., to disintegrate and release the API absent of any special rate-
controlling
features, such as special coatings and other techniques. In certain
embodiments, the
formulation is a rapidly disintegrating tablet that, e.g., dissolves
substantially in the mouth
following administration. In certain embodiments, the pharmaceutical
formulation is an
extended release tablet of a cytidine analog. In certain embodiments, the
extended release
tablet is designed, e.g., to release the API over an extended period of time
and substantially
in the stomach.
[00164] In certain embodiments, compressed tablets may be prepared by wet
granulation.
Wet granulation is a widely employed method for the production of compressed
tablets,
and, in particular embodiments, requires one or more the following steps: (1)
weighing and
blending the ingredients; (2) preparing a damp mass; (3) screening the damp
mass into
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pellets or granules; (4) drying the granulation; (5) sizing the granulation by
dry screening;
(6) adding lubricant and blending; and (7) tableting by compression.
[00165] In certain embodiments, compressed tablets may be prepared by dry
granulation.
By the dry granulation method, the powder mixture is compacted in large pieces
and
subsequently broken down or sized into granules. But this method, either the
active
ingredient or the diluent has cohesive property. After weighing and mixing the
ingredients,
the powder mixture may be slugged or compressed into large flat tablets or
pellets. The
slugs then are broken up by hand or by a mill and passed through a screen of
desired mesh
for sizing. Lubricant is added in the usual manner, and tablets are prepared
by compression.
Alternatively, instead of slugging, powder compactors may be used to increase
the density
of a powder by pressing it between high-pressure rollers. The compressed
material then is
broken up, sized, and lubricated, and tablets are prepared by compression in
the usual
manner. The roller compaction method is often preferred over slugging. Binding
agents
used in roller compaction formulations include methylcellul.ose or hydroxyl-
methylcellulose
and can produce good tablet hardness and friability.
[00166] In certain embodiments, compressed tablets may be prepared by direct
compression. Some granular chemicals possess free flowing and cohesive
properties that
enable them to be compressed directly in a tablet machine without the need of
wet or dry
granulation. For chemicals that do not possess this quality, special
pharmaceutical
excipients may be used which impart the necessary qualities for the production
of tablets by
direct compression. Particular tableti.ng excipients include, e.g.: fillers,
such as spray-dried
lactose, micro-crystals of alpha-monohydrate lactose, sucrose-invert sugar-
corn starch
mixtures, micro-crystalline cellulose, crystalline maltose, and di-calcium
phosphate;
disintegrating agents, such as direct-compression starch, sodium carboxymethyl
starch,
cross-linked carboxymethylcellul.ose fibers, and cross-linked
polyvinylpyrrolidone;
lubricants, such as magnesium searate and talc; and glidants, such as fumed
silicon dioxide.
[00167] In certain embodiments, tablets provided herein may be prepared by
molding.
The base for molded tablets is generally a mixture of finely powdered lactose
with or
without a portion of powdered sucrose. In preparing the fill, the drug is
mixed uniformly
with the base by geometric dilution. The powder mixture may be wetted with a
mixture of
water and alcohol sufficient only to dampen the powder so that it may be
compacted. The
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solvent action of the water on a portion of the lactose/sucrose base effects
the biding of the
powder mixture upon drying. The alcohol portion hastens the drying process.
[00168] In certain embodiments, the pharmaceutical formulations provided
herein
contain the cytidine analog and, optionally, one or more excipients to form a
"drug core."
Optional excipients include, e.g., diluents (bulking agents), lubricants,
disintegrants, fillers,
stabilizers, surfactants, preservatives, coloring agents, flavoring agents,
binding agents,
excipient supports, glidants, permeation enhancement excipients, plasticizers
and the like,
e.g., as known in the art. It will be understood by those in the art that some
substances serve
more than one purpose in a pharmaceutical composition. For instance, some
substances are
binders that help hold a tablet together after compression, yet are also
disintegrants that help
break the tablet apart once it reaches the target delivery site. Selection of
excipients and
amounts to use may be readily determined by the formulation scientist based
upon
experience and consideration of standard procedures and reference works
available in the
art.
[00169] In certain embodiments, formulations provided herein comprise one or
more
binders. Binders may be used, e.g., to impart cohesive qualities to a tablet,
and thus ensure
that the tablet remains intact after compression. Suitable binders include,
but are not limited
to, starch (including corn starch and pregelatinized starch), gelatin, sugars
(including
sucrose, glucose, dextrose and lactose), polyethylene glycol, propylene
glycol, waxes, and
natural and synthetic gums, e.g., acacia sodium alginate,
polyvinylpyrrolidone, cellulosic
polymers (including hydroxypropyl cellulose, hydroxypropylmethylcellulose,
methyl
cellulose, ethyl cellulose, hydroxyethyl cellulose, carboxymethyl cellulose
and the like),
veegum, carbomer (e.g., carbopol), sodium, dextrin, guar gum, hydrogenated
vegetable oil,
magnesium aluminum silicate, maltodextrin, polymethacrylates, povidone (e.g.,
KOLLIDON, PLASDONE), microoystal line cellulose, among others. Binding agents
also
include, e.g., acacia, agar, alginic acid, cabomers, carrageenan, cellulose
acetate phthalate,
ceratonia, chitosan, confectioner's sugar, copovidone, dextrates, dextrin,
dextrose,
ethylcellulose, gelatin, glyceryl behenate, guar gum, hydroxyethyl cellulose,
hydroxyethylmethyl cellulose, hydroxypropyl cellulose, hydroxypropyl starch,
hypromellose, inulin, lactose, magnesium aluminum silicate, maltodextrin,
maltose,
methylcellulose, poloxamer, polycarbophil, polydextrose, polyethylene oxide,
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polymethylacrylates, povidone, sodium alginate, sodium carboxymethylcellulose,
starch,
pregelatinized starch, stearic acid, sucrose, and zein. The binding agent can
be, relative to
the drug core, in the amount of about 2% w/w of the drug core; about 4% w/w of
the drug
core, about 6% w/w of the drug core, about 8% w/w of the drug core, about 10%
w/w of the
drug core, about 12% w/w of the drug core, about 14% w/w of the drug core,
about 16%
w/w of the drug core, about 18% w/w of the drug core, about 20% w/w of the
drug core,
about 22% w/w of the drug core, about 24% w/w of the drug core, about 26% w/w
of the
drug core, about 28% w/w of the drug core, about 30% wlw of the drug core,
about 32%
w/w of the drug core, about 34% w/w of the drug core, about 36% w/w of the
drug core,
about 38% wlw of the drug core, about 40% w/w of the drug core, about 42% w/w
of the
drug core, about 44% w/w of the drug core, about 46% w/w of the drug core,
about 48%
w/w of the drug core, about 50% w/w of the drug core, about 52% w/w of the
drug core,
about 54% w/w of the drug core, about 56% w/w of the drug core, about 58% w/w
of the
drug core, about 60% w/w of the drug core, about 62% w/w of the drug core,
about 64%
w/w of the drug core, about 66% w/w of the drug core; about 68% wlw of the
drug core,
about 70% w/w of the drug core, about 72% w/w of the drug core, about 74% w/w
of the
drug core, about 76% w/w of the drug core, about 78% wlw of the drug core,
about 80%
w/w of the drug core, about 82% w/w of the drug core, about 84% w/w of the
drug core,
about 86% wlw of the drug core, about 88% w/w of the drug core, about 90% w/w
of the
drug core, about 92% w/w of the drug core, about 94% w/w of the drug core,
about 96%
w/w of the drug core, about 98% w/w of the drug core, or more, if determined
to be
appropriate. In certain embodiments, a suitable amount of a particular binder
is determined
by one of ordinary skill in the art.
[001701 In certain embodiments, formulations provided herein comprise one or
more
diluents. Diluents may be used, e.g., to increase bulk so that a practical
size tablet is
ultimately provided. Suitable diluents include dicalcium phosphate, calcium
sulfate,
lactose, cellulose, kaolin, mannitol, sodium chloride, dry starch,
microcrystalline cellulose
(e.g., AVICEL), microfine cellulose, pregelitinized starch, calcium carbonate,
calcium
sulfate, sugar, dextrates, dextrin, dextrose, dibasic calcium phosphate
dihydrate, tribasic
calcium phosphate, kaolin, magnesium carbonate, magnesium oxide, maltodextrin,
mannitol, polymethacrylates (e.g., ELTDRAGIT), potassium chloride, sodium
chloride,
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sorbitol and talc, among others. Diluents also include, e.g., ammonium
alginate, calcium
carbonate, calcium phosphate, calcium sulfate, cellulose acetate, compressible
sugar,
confectioner's sugar, dextrates, dextrin, dextrose, erythritol,
ethylcellulose, fructose,
fumaric acid, glyceryl palmitostearate, isomalt, kaolin, lacitol, lactose,
mannitol,
magnesium. carbonate, magnesium oxide, maltodextrin, maltose, medium-chain
triglycerides, rnicrocrystalline cellulose, microcrystalline silicified
cellulose, powered
cellulose, polydextrose, polymethylacrylates, simethicone, sodium alginate,
sodium
chloride, sorbitol, starch, pregelatinized starch, sucrose, sulfobutylether-I3-
cyclodextrin, talc,
tragacanth, trehalose, and xylitol. Diluents may be used in amounts calculated
to obtain a
desired volume for a tablet or capsule; in certain embodiments, a diluent is
used in an
amount of about 5% or more, about 10% or more, about 15% or more, about 20% or
more,
about 22% or more, about 24% or more, about 26% or more, about 28% or more,
about
30% or more, about 32% or more, about 34% or more, about 36% or more, about
38% or
more, about 40% or more, about 42% or more, about 44% or more, about 46% or
more,
about 48% or more, about 50% or more, about 52% or more, about 54% or more,
about
56% or more, about 58% or more, about 60% or more, about 62% or more, about
64% or
more, about 68% or more, about 70% or more, about 72% or more, about 74% or
more,
about 76% or more, about 78% or more, about 80% or more, about 85% or more,
about
90% or more, or about 95% or more, weight/weight, of a drug core; between
about 10% and
about 90% w/w of the drug core; between about 20% and about 80% w/w of the
drug core;
between about 30% and about 70% w/w of the drug core; between about 40% and
about
60% w/w of the drug core. In certain embodiments, a suitable amount of a
particular
diluent is determined by one of ordinary skill in the art.
[001711 In certain embodiments, formulations provided herein comprise one or
more
lubricants. Lubricants may be used, e.g., to facilitate tablet manufacture;
examples of
suitable lubricants include, for example, vegetable oils such as peanut oil,
cottonseed oil,
sesame oil, olive oil, corn oil, and oil of theobroma, glycerin, magnesium
stearate, calcium
stearate, and stearic acid. In certain embodiments, stearates, if present,
represent no more
than approximately 2 weight % of the drug-containing core. Further examples of
lubricants
include, e.g., calcium stearate, glycerin monostearate, gl.yceryl behenate,
glyceryl
palmitostearate, magnesium lauryl sulfate, magnesium stearate, myristic acid,
palmitic acid,
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poloxamer, polyethylene glycol, potassium benzoate, sodium benzoate, sodium
chloride,
sodium. lauryi sulfate, sodium stearyi fumarate, stearic acid, talc, and zinc
stearate. In
particular embodiments, the lubricant is magnesium stearate. In certain
embodiments, the
lubricant is present, relative to the drug core, in an amount of about 0.2%
w/w of the drug
core, about 0.4% w/w of the drug core, about 0.6% w/w of the drug core, about
0.8% w/w
of the drug core, about 1.0% w/w of the drug core, about 1.2% w/w of the drug
core, about
1.4% w/w of the drug core, about 1.6% w/w of the drug core, about 1.8% w/w of
the drug
core, about 2.0% w/w of the drug core, about 2.2% w/w of the drug core, about
2.4% w/w
of the drug core, about 2.6% w/w of the drug core, about 2.8% w/w of the drug
core, about
3.0% w/w of the drug core, about 3.5% w/w of the drug core, about 4% w/w of
the drug
core, about 4.5% w/w of the drug core, about 5% w/w of the drug core, about 6%
w/w of
the drug core, about 7% w/w of the drug core, about 8% w/w of the drug core,
about 10%
w/w of the drug core, about 12% w/w of the drug core, about 14% w/w of the
drug core,
about 16% w/w of the drug core, about 18% w/w of the drug core, about 20% w/w
of the
drug core, about 25% w/w of the drug core, about 30% w/w of the drug core,
about 35%
w/w of the drug core, about 40% w/w of the drug core, between about 0.2% and
about 10%
wlw of the drug core, between about 0.5% and about 5% w/w of the drug core, or
between
about 1% and about 3% w/w of the drug core. In certain embodiments, a suitable
amount of
a particular lubricant is determined by one of ordinary skill in the art.
[00172] In certain embodiments, formulations provided herein comprise one or
more
disintegrants. Disintegrants may be used, e.g., to facilitate disintegration
of the tablet, and
may be, e.g., starches, clays, celluloses, algins, gums or crosslinked
polymers.
Disintegrants also include, e.g., alginic acid, carboxymethylcellulose
calcium,
carboxymethylcellulose sodium (e.g., AC-D1-SOL, PRIMELLOSE), colloidal silicon
dioxide, croscarmellose sodium, crospovidone (e.g., KOLLIDON, POLYPLA.SDONE),
guar gum, magnesium aluminum silicate, methyl cellulose, microcrystalline
cellulose,
polacrilin potassium., powdered cellulose, pregelatinized starch, sodium.
alginate, sodium.
starch glycolate (e.g., EXPLOTAB) and starch. Additional disintegrants
include, e.g.,
calcium alginate, chitosan, sodium docusate, hydroxypropyl cellulose, and
povidone. In
certain embodiments, the disintegrant is, relative to the drug core, present
in the amount of
about 1% w/w of the drug core, about 2% w/w of the drug core, about 3% w/w of
the drug
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core, about 4% w/w of the drug core, about 5% w/w of the drug core, about 6%
w/w of the
drug core, about 7% w/w of the drug core, about 8% w/w of the drug core, about
9% wlw of
the drug core, about 10% w/w of the drug core, about 12% w/w of the drug core,
about 14%
w/w of the drug core, about 16% w/w of the drug core, about 18% w/w of the
drug core,
about 20% w/w of the drug core, about 22% w/w of the drug core, about 24% w/w
of the
drug core, about 26% w/w of the drug core, about 28% w/w of the drug core,
about 30%
w/w of the drug core, about 32% w/w of the drug core, greater than about 32%
w/w of the
drug core, between about 1% and about 10% w/w of the drug core, between about
2% and
about 8% w/w of the drug core, between about 3% and about 7% w/w of the drug
core, or
between about 4% and about 6% w/w of the drug core. In certain embodiments, a
suitable
amount of a particular disintegrant is determined by one of ordinary skill in
the art.
[00173] In certain embodiments, formulations provided herein comprise one or
more
stabilizers. Stabilizers (also called absorption enhancers) may be used, e.g.,
to inhibit or
retard drug decomposition reactions that include, by way of example, oxidative
reactions.
Stabilizing agents include, e.g., d-Alpha-tocopheryl polyethylene glycol 1000
succinate
(Vitamin E TPGS), acacia, albumin, alginic acid, aluminum stearate, ammonium
alginate,
ascorbic acid, ascorbyl palmitate, bentonite, butylated hydroxytoluene,
calcium alginate,
calcium stearate, calcium carboxymethylcellulose, carrageenan, ceratonia,
colloidal silicon
dioxide, cyclodextrins, diethanolamine, edetates, ethylcellulose,
ethyleneglycol
palmitostearate, glycerin monostearate, guar gum, hydroxypropyl cellulose,
hypromellose,
invert sugar, lecithin, magnesium aluminum silicate, monoethanolamine, pectin,
poloxamer,
polyvinyl alcohol, potassium alginate, potassium polacrilin, povidone, propyl
gallate,
propylene glycol, propylene glycol alginate, raffinose, sodium acetate, sodium
alginate,
sodium borate, sodium carboxymethyl cellulose, sodium stearyl fumarate,
sorbitol, stearyl
alcohol, sufobutyl-b-cyclodextrin, trehalose, white wax, xanthan gum, xylitol,
yellow wax,
and zinc acetate. In certain embodiments, the stabilizer is, relative to the
drug core, present
in the amount of about 1% w/w of the drug core, about 2% w/w of the drug core,
about 3%
w/w of the drug core, about 4% w/w of the drug core, about 5% w/w of the drug
core, about
6% w/w of the drug core, about 7% w/w of the drug core, about 8% w/w of the
drug core,
about 9% w/w of the drug core, about 10% w/w of the drug core, about 12% w/w
of the
drug core, about 14% w/w of the drug core, about 16% w/w of the drug core,
about 18%
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w/w of the drug core, about 20% w/w of the drug core, about 22% w/w of the
drug core,
about 24% w/w of the drug core, about 26% w/w of the drug core, about 28% w/w
of the
drug core, about 30% w/w of the drug core, about 32% w/w of the drug core,
between about
1% and about 10% w/w of the drug core, between about 2% and about 8% w/w of
the drug
core, between about 3% and about 7% w/w of the drug core, or between about 4%
and
about 6% w/w of the drug core. In certain embodiments, a suitable amount of a
particular
stabilizer is determined by one of ordinary skill in the art.
[00174] In certain embodiments, formulations provided herein comprise one or
more
glidants. Glidants may be used, e.g., to improve the flow properties of a
powder
composition or granulate or to improve the accuracy of dosing. Excipients that
may
function as glidants include, e.g., colloidal silicon dioxide, magnesium
trisilicate, powdered
cellulose, starch, tribasic calcium phosphate, calcium silicate, powdered
cellulose, colloidal
silicon dioxide, magnesium silicate, magnesium trisilicate, silicon dioxide,
starch, tribasic
calcium phosphate, and talc. In certain embodiments, the glidant is, relative
to the drug
core, present in the amount of less than about 1% w/w of the drug core, about
1% w/w of
the drug core, about 2% w/w of the drug core, about 3% w/w of the drug core,
about 4%
wlw of the drug core, about 5% w/w of the drug core, about 6% w/w of the drug
core, about
7% w/w of the drug core, about 8% w/w of the drug core, about 9% w/w of the
drug core,
about 10% wlw of the drug core, about 12% w/w of the drug core, about 14% w/w
of the
drug core, about 16% w/w of the drug core, about 18% w/w of the drug core,
about 20%
w/w of the drug core, about 22% w/w of the drug core, about 24% w/w of the
drug core,
about 26% w/w of the drug core, about 28% w/w of the drug core, about 30% w/w
of the
drug core, about 32% w/w of the drug core, between about 1% and about 10% w/w
of the
drug core, between about 2% and about 8% w/w of the drug core, between about
3% and
about 7% w/w of the drug core, or between about 4% and about 6% w/w of the
drug core.
In certain embodiments, a suitable amount of a particular glidant is
determined by one of
ordinary skill in the art.
[00175] In certain embodiments, formulations provided herein comprise one or
more
permeation enhancers (also called, e.g., permeability enhancers). In certain
embodiments,
the permeation enhancer enhances the uptake of a cytidine analog through the
gastrointestinal wall (e.g., the stomach). In certain embodiments, the
permeation enhancer
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alters the rate and/or amount of the cytidine analog that enters the
bloodstream. In
particular embodiments, d-alpha-tocopheryl polyethylene glycol-1000 succinate
(Vitamin E
'I'PGS) is used as a permeation enhancer. In particular embodiments, one or
more other
suitable permeation enhancers are used, including, e.g., any permeation
enhancer known in
the art. Specific examples of suitable permeation enhancers include, e.g.,
those listed
below:
Example of
Product name Chemical Name Supplier
Pluronic F 127 Poloxamer F 127 Sigma
Lutrol F 68 Poloxamer 188 BASF
Carbopol 934-P Carbomer 934-P Spectrum
Chemical
Tween 80 Polysorbate 80 Sigma
Chitosan Chitosan .Low :Mol Wt Aldrich
Capric acid/Na cap Sodium Decanoate Sigma
Laurie acid/Na laur Sodium Dodecanoate Sigma
Disodium EDTA Ethylenediamine tetraacetic acid Sigma
disodium dehydrate
Propylene glycol 1, 2 Propanediol Sigma
CM Cellulose Carboxymethyl Cellulose Sigma
Labrasol Caprylocaproyl macrogo1-8 glycerides Gattefosse
N,N- Dimethylacetamide (minimum 99%) Sigma
Vitamin E TPGS d-Alpha-Tocopheryl Polyethylene Eastman
Glycol-1000 Succinate
Solutol HS 15 Polyethylene glycol 660 12- BASF
hydroxystearate
Labrafil M 1944 CS (2) Oleyl Macrogolglyerides Gaftefosse
[00176] Other potential permeation enhancers include, e.g., alcohols,
di.m.ethyl sulfoxide,
glyceryl monooleate, glycofitrol, isopropyl myristate, isopropyl palmitate,
lanolin, linoleic
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acid, myristic acid, oleic acid, oleyl alcohol, palmitic acid, polyoxyethylene
alkyl ethers, 2-
pyrrolidon.e, sodium lauryl sulfate, and thymol..
[00177] In certain embodiments, the permeation enhancer is present in the
formulation in
an amount by weight, relative to the total weight of the formulation, of about
0.1%, about
0.2%, about 0.3%, about 0.4%, about 0.5%, about 0.6%, about 0.7%, about 0.8%,
about
0.9%, about 1%, about 1.1%, about 1.2%, about 1.3%, about 1.4%, about 1.5%,
about 1.6%,
about 1.7%, about 1.8%, about 1.9%, about 2%, about 2.1%, about 2.2%, about
2.3%, about
2.4%, about 2.5%, about 2.6%, about 2.7%, about 2.8%, about 2.9%, about 3%,
about 3.1%,
about 3.2%, about 3.3%, about 3.4%, about 3.5%, about 3.6%, about 3.7%, about
3.8%,
about 3.9%, about 4%, about 4.1% about 4.2%, about 4.3%, about 4.4%, about
4.5%, about
4.6%, about 4.7%, about 4.8%, about 4.9%, about 5%, about 5.1% about 5.2%,
about 5.3%,
about 5.4%, about 5.5%, about 5.6%, about 5.7%, about 5.8%, about 5.9%, about
6%, about
6.1% about 6.2%, about 6.3%, about 6.4%, about 6.5%, about 6.6%, about 6.7%,
about
6.8%, about 6.9%, about 7%, about 7.1% about 7.2%, about 7.3%, about 7.4%,
about 7.5%,
about 7.6%, about 7.7%, about 7.8%, about 7.9%, about 8%, about 8.1% about
8.2%, about
8.3%, about 8.4%, about 8.5%, about 8.6%, about 8.7%, about 8.8%, about 8.9%,
about 9%,
about 9.1% about 9.2%, about 9.3%, about 9.4%, about 9.5%, about 9.6%, about
9.7%,
about 9.8%, about 9.9%, about 10%, greater than about 10%, greater than about
12%,
greater than about 14%, greater than about 16%, greater than about 18%,
greater than about
20%, greater than about 25%, greater than about 30%, greater than about 35%,
greater than
about 40%, greater than about 45%, or greater than about 50%. In certain
embodiments, the
appropriate amount of a suitable permeation enhancer provided herein is
determined by one
of skill in the art.
[00178] Without intending to be limited to any particular theory, the
permeation
enhancers provided herein may function by, inter alia, facilitating (e.g.,
increasing the rate
or extent of) the transport of a cytidine analog through the gastrointestinal
wall. In general,
movement through the gastrointestinal wall may occur by, e.g.: passive
diffusion, such as
the movement of drug across a membrane in a manner driven solely by the
concentration
gradient; carrier-mediated diffusion, such as the movement of drug across a
cell membrane
via a specialized transport system embedded in the cell membrane; paracellular
diffusion,
such as the movement of a drug across a membrane by going between, rather than
through,
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two cells; and transcellular diffusion, such as the movement of a drug across
the cell.
Additionally, there are numerous cellular proteins capable of preventing
intracellular
accumulation of drugs by pumping out drug that enters the cell. These are
sometimes called
efflux pumps. One such efflux pump is that involving p-glycoprotein, which is
present in
many different tissues in the body (e.g., intestine, placental membrane, blood-
brain barrier).
Permeation enhancers can function by, inter alia, facilitating any of the
processes mentioned
above (such as by increasing fluidity of membranes, opening tight junctions
between cells,
and/or inhibiting efflux, among others).
[00179] In certain embodiments, the compositions provided herein comprising a
cytidine
analog, e.g., 5-azacytidine, are essentially free of a cytidine deaminase
inhibitor (e.g., do not
comprise a cytidine deaminase inhibitor). In certain embodiments, the
compositions
provided herein are essentially free of (e.g., do not comprise) the cytidine
deaminase
inhibitor tetrahydrouridine (THU). Certain embodiments herein provide
pharmaceutical
compositions comprising a therapeutically effective amount of a cytidine
analog (e.g., 5-
azacytidine), wherein the compositions release the cytidine analog
substantially in the
stomach following oral administration to a subject, and wherein the
compositions are
essentially free of (e.g., do not comprise) a cytidine deaminase inhibitor
(e.g., THU).
Certain embodiments herein provide pharmaceutical compositions comprising a
therapeutically effective amount of a cytidine analog (e.g., 5-azacytidine),
wherein the
compositions release the cytidine analog substantially in the stomach
following oral
administration to a subject, wherein the compositions are essentially free of
(e.g., do not
comprise) a cytidine deaminase inhibitor (e.g., THU), and wherein the
compositions achieve
a particular biological parameter provided herein (e.g., a particular Cmax
value, Im.ax
value, and/or AUC value provided herein). In particular embodiments, a
composition
provided herein that is essentially free of a cytidine deaminase inhibitor
(e.g., THU)
comprises, e.g., less than 200 mg, less than 150 mg, less than 100 mg, less
than 50 mg, less
than 25 mg, less than 10 mg, less than 5 mg, less than 1 mg, or less than 0.1
mg of the
cytidine deaminase inhibitor.
4. Additional Therapeutic Agents
[00180] In particular embodiments, the cytidine analog oral formulations
provided herein
further comprise one, two, three, or more other pharmacologically active
substances (also
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termed herein "additional therapeutic agents," "second active agents," or the
like). In
particular embodiments, the oral formulations provided herein comprise the
additional
therapeutic agent(s) in a therapeutically effective amount. in particular
embodiments, the
cytidine analog (e.g., 5-azacytidine) and the additional therapeutic agent(s)
are co-
formulated together in the same dosage form using methods of co-formulating
active
pharmaceutical ingredients, including methods disclosed herein and methods
known in the
art. In other embodiments, the cytidine analog and the additional therapeutic
agent(s) are
co-administered in separate dosage forms. It is believed that certain
combinations work
synergistically in the treatment of particular diseases or disorders,
including, e.g., types of
cancer and certain diseases and conditions associated with, or characterized
by, undesired
angiogenesis or abnormal cell proliferation. Cytidine analog oral dosage forms
provided
herein can also work to alleviate adverse effects associated with certain
second active
agents, and some second active agents can be used to alleviate adverse effects
associated
with cytidine analog oral dosage forms provided herein. In certain
embodiments, the oral
formulations provided herein are co-administered with one or more therapeutic
agents to
provide a resensitization effect in subjects in need thereof. Additional
therapeutic agents
can be, e.g., large molecules ( e.g., proteins) or small molecules (e.g.,
synthetic inorganic,
organometallic, or organic molecules). In a particular embodiment, the one or
more
additional therapeutic agent(s) include, but are not limited to, an anti-PD
1/anti-PDL1
monoclonal antibody such as pembrolizumab and MEDI4736 (Durvalumab).
[00181] Examples of particular additional therapeutic agents useful in the
compositions
and methods disclosed herein include, but are not limited to, e.g., cytotoxic
agents, anti-
m.etabolites, an.tifolates, HDAC inhibitors (e.g., entinostat, also known as
SNDX-275 or
MS-275; or vorinostat, also known as suberoylanilide hydroxamic acid (SAHA) or
N-
hydroxy-N'-phenyl-octanediamide), DNA. intercalating agents, DNA cross-linking
agents,
DNA alkylating agents, DNA cleaving agents, topoisomerase inhibitors, CDK
inhibitors,
JA.K inhibitors, anti-angiogenic agents, Bcr-Abl. inhibitors, HER2 inhibitors,
EGFR
inhibitors, VEGFR inhibitors, PDGFR inhibitors, HGFR inhibitors, IGFR
inhibitors, c-Kit
inhibitors, Ras pathway inhibitors, PI3K inhibitors, multi-targeted kinase
inhibitors, mTOR
inhibitors, anti-estrogens, anti-androgens, aromatase inhibitors, somatostatin
analogs, ER
modulators, anti-tubulin agents, vinca alkaloids, taxanes, HSP inhibitors,
Smoothened
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antagonists, telomerase inhibitors, COX-2 inhibitors, anti-metastatic agents,
immunosuppressants, biologics such as antibodies, and hormonal therapies. In
particular
embodiments, the co-administered therapeutic agent is an immunomodulatory
compound,
e.g., thalidomide, lenalidomide, or pomalidomide. The co-administered agent
may be
dosed, e.g., orally or by injection.
[00182] Other examples of additional therapeutic agents include, but are not
limited to,
hematopoietic growth factor, a cytokine, an anti-cancer agent, granulocyte
colony-
stimulating factor (G-CSF), granulocyte-macrophage colony-stimulating factor
(GM-CSF),
erythropoietin (EPO), interleukin (IL), interferon (IFN), oblimersen,
melphalan, topotecan,
pentoxifylline, taxotere, irinotecan, ciprofloxacin, doxorubicin, vincristine,
dacarbazine,
Ara-C, vinorelbine, prednisone, cyclophosphamide, bortezomib, arsenic
trioxide. Such
additional therapeutic agents are particularly useful in methods and
compositions disclosed
herein including, but not limited to, those relating to treatment of multiple
myeloma.
[00183] Other examples of additional therapeutic agents include, but are not
limited to,
an antibody (e.g., rituximab, anti-CD33), hematopoietic growth factor,
cytokine, anti-cancer
agent, antibiotic, cox-2 inhibitor, immunomodulatory agent, immunosuppressive
agent,
corticosteroid, or a pharmacologically active mutant or derivative thereof.
See, e.g., S.
Nand et al., Leukemia and Lymphoma, 2008, 49(11):2141-47 (describing a Phase H
study
involving the administration of a combination of hydroxyurea, azacitidine and
low dose
gemtuzurnab ozogamicin to elderly patients with AML and high-risk MDS, and
concluding
that this combination appears to be a safe and effective regimen in the
treatment of AML
and high risk MDS in this group of patients). Such additional therapeutic
agents are
particularly useful in methods and compositions disclosed herein including,
but not limited
to, those relating to treatment of the diseases and disorders disclosed
herein.
[00184] Examples of large molecule active agents include, but are not limited
to,
hematopoietic growth factors, cytokines, and monoclonal and polyclonal
antibodies.
Typical large molecule active agents are biological molecules, such as
naturally occurring
or artificially made proteins. Proteins that are particularly useful include
proteins that
stimulate the survival andlor proliferation of hematopoietic precursor cells
and
immunologically active poietic cells in vitro or in vivo. Others stimulate the
division and
differentiation of committed erythroid progenitors in cells in vitro or in
vivo. Particular
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proteins include, but are not limited to: interleukins, such as IL-2
(including recombinant
IL-II ("rIL2") and can.arypox IL-2), IL-10, IL-12, and IL-18; interferons,
such as interferon
al.fa-2a, interferon alfa-2b, interferon alfa-nl, interferon alfa-n3,
interferon beta-1 a, and
interferon gamma-I b; GM-CF and GM-CSF; and EPO.
[00185] Particular proteins that can be used in the methods and compositions
provided
herein include, but are not limited to: filgrastim, which is sold in the
United States under
the trade name Neupogen (Amgen, Thousand Oaks, CA); sargramostim, which is
sold in
the United States under the trade name Leulcine (Immunex, Seattle, WA); and
recombinant
EPO, which is sold in the United States under the trade name Epogen (Amgen,
Thousand
Oaks, CA).
[00186] Recombinant and mutated forms of GM-CSF can be prepared as described
in
U.S. patent nos. 5,391,485; 5,393,870; and 5,229,496; all of which are
incorporated herein
by reference. Recombinant and mutated forms of G-CSF can be prepared as
described in
U.S. patent nos. 4,810,643; 4,999,291; 5,528,823; and 5,580,755; all of which
are
incorporated herein by reference.
[00187] Embodiments herein encompass the use of native, naturally occurring,
and
recombinant proteins. Particular embodiments encompass mutants and derivatives
(e.g.,
modified forms) of naturally occurring proteins that exhibit, in vivo, at
least some of the
pharmacological activity of the proteins upon which they are based. Examples
of mutants
include, but are not limited to, proteins that have one or more amino acid
residues that differ
from the corresponding residues in the naturally occurring forms of the
proteins. Also
encompassed by the term "mutants" are proteins that lack carbohydrate moieties
normally
present in their naturally occurring forms (e.g., nonglycosylated forms).
Examples of
derivatives include, but are not limited to, pegylated derivatives and fusion
proteins, such as
proteins formed by fusing IgGl. or 1g03 to the protein or active portion of
the protein of
interest. See, e.g., Penichet, M.L. and Morrison, S.L., J. Immunol. Methods
248:91-101
(2001).
[00188] Antibodies that can be used in combination with oral formulations
disclosed
herein include monoclonal and polyclonal antibodies. Examples of antibodies
include, but
are not limited to, trastuzumab (Herceptin0), rittucimab (Ritaxang),
bevacizumab
(AvastinTm), pertuzumab (OmnitargTm), tositumomab (Bexxare), edrecolomab
(Panorex0),
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and G250. Oral formulations disclosed herein can also comprise, be combined
with, or used
in combination with anti-TNF-a antibodies. In a preferred embodiment, the
antibody is an
anti-l?Dlianti-PDLI monoclonal antibody such as pembrolizumab and M ED14736
(Durvalumab).
[00189] Large molecule active agents may be administered in the form of anti-
cancer
vaccines. For example, vaccines that secrete, or cause the secretion of,
cytokines such as
1L-2, G-CSF, and GM-CSF can be used in the methods, pharmaceutical
compositions, and.
kits provided herein. See, e.g., Emens, L.A., et al., Curr. Opinion Mol. Ther.
3(1):77-84
(2001).
[00190] In one embodiment, the additional therapeutic agent (e.g., large-
molecule
compound or small-molecule compound) reduces, eliminates, or prevents an
adverse effect
associated with the administration (e.g., oral administration.) of a cytidine
analog provided
herein. Depending on the particular cytidine analog and the disease or
disorder begin
treated, adverse effects can include, but are not limited to, anemia,
neutropenia, febrile
neutropenia, thrombocytopenia, hepatotoxicity (e.g., including, but not
limited to,
hepatoxi.city in patients with preexisting hepatic impairment), elevated serum
creatinine,
renal failure, renal tubular acidosis, hypokalemia, hepatic coma, nausea,
vomiting,
dyspepsia, abdominal pain, pyrexia, leukopenia, diarrhea, constipation,
ecchymosi.s,
petechiae, rigors, weakness, pneumonia, anxiety, insomnia, lethargy, and
decrease in
weight, among others known in the art to be associated with particular
cytidine analogs.
[00191] Like some large molecules, many small-molecule compounds are believed
to be
capable of providing a synergistic effect when administered with (e.g.,
before, after or
simultaneously) a cytidine analog oral formulation disclosed herein. Examples
of small
molecule second active agents include, but are not limited to, anti-cancer
agents, antibiotics,
imm.unosuppressive agents, and steroids.
[00192] Examples of anti-cancer agents include, but are not limited to:
acivicin;
aclanthicin; acod.azole hydrochloride; acronine; adozelesin; aldesleukin;
altretamine;
ambomycin; ametan.tron.e acetate; amsacrine; anastrozole; anthramycin;
asparaginase;
asperlin; azacitidine; azetepa; azotomycin; batimastat; benzodepa;
bicalutamide; bisantrene
hydrochloride; bisnafi.de dimesylate; bizel.esin; bleomycin sulfate; brequinar
sodium;
bropirimine; busulfan; cactinomycin; calusterone; caracemide; carbetimer;
carboplatin;
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carmustine; carubicin hydrochloride; carzelesin; cedefingol; celecoxib (COX-2
inhibitor);
chlorambucil; cirolem.ycin; cisplati.n; cl.adribine; crisn.atol mesylate;
cyclophosphamide;
cytarabine; dacarbazine; dactinomycin; daunorubicin hydrochloride; decitabine;
dexormaplatin; dezaguanine; dezaguanine mesylate; diaziquone; docetaxel;
doxorubicin;
doxorubicin hydrochloride; droloxifene; droloxifene citrate; dromostanolone
propionate;
duazomycin; edatrexate; eflomithine hydrochloride; elsamitrucin; enloplatin;
enpromate;
epipropidine; epirubicin hydrochloride; erbulozole; esorubicin hydrochloride;
estramustine;
estramustine phosphate sodium; etanidazole; etoposide; etoposide phosphate;
etoprine;
fadrozole hydrochloride; fazarabine; fenretinide; floxuridine; fludarabine
phosphate;
fluorouracil; flurocitabine; fosquidone; fostriecin sodium; gemcitabine;
gemcitabine
hydrochloride; hydroxyurea; idarubicin hydrochloride; ifosfamide; ilmofosine;
iproplafin;
irinotecan; irinotecan hydrochloride; lanreotide acetate; letrozol.e;
leuprolide acetate;
liarozole hydrochloride; lometrexol sodium; lomustine; losoxantrone
hydrochloride;
m.asoprocol; maytan.si.ne; mechlorethamine hydrochloride; megestrol acetate;
melengestrol
acetate; melphalan; menogaril; mercaptopurine; methotrexate; methotrexate
sodium;
metoprine; meturedepa; mi.tindom.ide; mitocarcin; mitocromin; mitogillin;
mitomalcin;
mitomycin; mitosper; mitotane; mitoxantrone hydrochloride; mycophenolic acid;
nocodazole; n.ogalamycin; ormapl.atin; oxisuran; pacl.itaxel; pegaspargase;
peliomycin.;
pentamustine; peplomycin sulfate; perfosfamide; pipobroman; piposulfan;
piroxantrone
hydrochloride; plicamycin; plomestane; porfimer sodium; porfiromycin;
prednimustine;
procarbazine hydrochloride; puromycin; puromyci.n hydrochloride; pyrazofitrin;
riboprine;
safingol; safingol hydrochloride; semustine; simtrazene; sparfosate sodium;
sparsomycin;
spirogermanium hydrochloride; spiromustine; spiroplatin; streptonigrin;
streptozocin;
sulofenur; talisomycin; tecogalan sodium; taxotere; tegafur; teloxantrone
hydrochloride;
temoporfin; teniposide; teroxirone; testolactone; thiamiprine; thioguanine;
thiotepa;
tiazofurin; tirapazamine; toremifene citrate; trestolone acetate; triciribine
phosphate;
trimetrexate; trimetrexate glucuronate; triptorelin; tubulozol.e
hydrochloride; uracii mustard;
uredepa; vapreotide; verteporfin; vinblastine sulfate; vincristine sulfate;
vindesin.e;
vindesine sulfate; vinepidine sulfate; vinglycinate sulfate; vinleurosine
sulfate; vinorelbine
tartrate; vinrosidin.e sulfate; vinzolidine sulfate; vorozole; zeniplatin;
zinostatin; and
zorubicin hydrochloride.
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[001931 Other anti-cancer drugs include, but are not limited to: 20-epi-1,25
dihydroxyvitamin D3; 5-ethynyluracil.; abiraterone; acl.arubicin; acylfulvene;
adecypen.ol;
adozelesin.; aldesleukin; ALL-TK antagonists; altretamin.e; ambamustine;
ami.dox;
amifostine; aminolevulinic acid; amntbicin; amsacrine; anagrelide;
anastrozole;
andrographolide; angi.ogenesis inhibitors; antagonist D; antagonist G;
antarelix;
anti-dorsalizing morphogenetic protein-1; antiandrogen, prostatic carcinoma;
antiestrogen;
antineoplaston; antisense oligonu.cleotid.es; aphidicolin glycinate; apoptosis
gene
modulators; apoptosis regulators; apurinic acid; ara-CDP-DL-PTBA; arginine
deaminase;
asulacrine; atamestane; atrimustine; axin.astatin 1; axin.astatin 2;
axinastatin 3; azasetron.;
azatoxin; azatyrosine; baccatin III derivatives; balanol; batimastat; BCR/ABL
antagonists;
benzochlorins; benzoylstaurosporine; beta lactam derivatives; beta-alethine;
betaclamycin
B; betulinic acid; .bFGF inhibitor; bicalutamide; bisantrene;
bisaziridi.nyl.spermi.ne;
bisnafide; bistratene A; bizelesin; breflate; bropirimine; budotitane;
buthionine sulfoximine;
calcipotriol; calphostin C; camptotheci.n derivatives; capecitabine;
carboxamide-amino-triazole; carboxyamidotriazole; CaRest M3; CARN 700;
cartilage
derived inhibitor; carzelesin; casein ki.nase inhibitors (ICOS);
castanospermine; cecropin B;
cetrorelix; chlorins; chloroquinoxaline sulfonamide; cicaprost; cis-poiphyrin;
cladribine;
clomifene analogues; clotrim.azole; col.lismycin .A; colli.smyci.n B;
combretastatin A.4;
combretastatin analogue; conagenin; crambescidin 816; crisnatol; cryptophycin
8;
cryptophycin A derivatives; curacin A; cyclopentanthraquinones; cycloplatam;
cypemycin;
cytarabine ocfosfate; cytolytic factor; cytostatin; dacliximab; decitabine;
dehydrodidemnin
B; deslorelin; dexamethasone; dexifosfamide; dexrazoxane; dexverapamil;
diaziquone;
didemnin B; didox; diethylnorspermine; di.hydro-5-azacytidine; dihydrotaxol, 9-
;
dioxamycin; diphenyl spiromustine; docetaxel; docosanol; dolasetron;
doxifluridine;
doxorubicin; droloxifene; dronabinol; duocarmycin SA; ebselen; ecomustine;
edelfosine;
edrecolomab; eflomithine; elemene; ernitefur; epirubicin; epristeride;
estramustine
analogue; estrogen agonists; estrogen antagonists; etanid.azole; etoposide
phosphate;
exemestane; fadrozole; fazarabine; fenretinide; filgrastim; finasteride;
flavopiridol;
flezelastine; fluasterone; fludarabine; fluorodaunorunicin hydrochloride;
forfenimex;
formestane; fostriecin; fotemustine; gadolinium texaphyri.n; gallium nitrate;
galocitabine;
ganirelix; gelatinase inhibitors; gerncitabine; giutathione inhibitors;
hepsulfarn; heregulin;
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hexamethylene bisacetamide; hypericin; ibandronic acid; idarubicin; idoxifene;
idramantone; ilmofosine; ilomastat; imatinib (e.g., Gleevec ), imiquimod;
imm.unostimulant
peptides; insulin-like growth factor-1 receptor inhibitor; interferon
agonists; interferons;
interleukins; iobenguane; iododoxorubicin; ipomeanol, 4-; iroplact;
irsogladine;
isobengazole; isohomohalicon.drin. B; itasetron; jasplakinolide; kahalali.de
F; lamel.larin-N
triacetate; lanreotide; leinamycin; lenograstim; lentinan sulfate;
leptolstatin; letrozole;
leukemia inhibiting factor; leukocyte alpha interferon; leuprolide-l-
estrogen+progesterone;
leuprorelin; levamisole; liarozole; linear polyamine analogue; lipophilic
disaccharide
peptide; lipophili.c platinum compounds; lissoclinamide 7; lobaplatin;
lombricin.e;
lometrexol; lonidamine; losoxantrone; loxoribine; lurtotecan; lutetium
texaphyrin;
lysofylline; lytic peptides; maitansine; mannostatin A; marimastat;
masoprocol; maspin;
matrilysin inhibitors; matrix metalloproteinase inhibitors; menogaril;
merbarone; metereli.n;
methioninase; metoclopramide; MIF inhibitor; mifeptistone; miltefosine;
mirimostim;
m.itoguazone; mitolactol; mitomycin analogues; mitonafide; mi.totoxin
fibroblast growth
factor-saporin; mitoxantrone; mofarotene; molgramostim;Erbitux, human
chorionic
gon.adotrophin; monophosphoryl lipid A-+-myobacterium cell wall sk; mopidamol;
mustard
anticancer agent; mycaperoxide B; mycobacterial cell wall extract;
myriaporone;
N-acetyldinal.in.e; N-substituted benzamides; nafarelin; nagrestip; n.aloxon.e-
+pentazocine;
napavin; naphterpin; nartograstim; nedaplatin; nemorubicin; neridronic acid;
nilutarnide;
nisamycin; nitric oxide modulators; nitroxide antioxidant; nitrullyn;
oblimersen
(Genasense ; 06-benzylguanine; octreotide; okicenone; oligonucleotides;
onapristone;
ondansetron; ondansetron; oracin; oral cytokine inducer; ormaplatin;
osaterone; oxaliplatin;
oxaunomycin; paclitaxel; paclitaxel analogues; paclitaxel derivatives;
palauam.ine;
palmitoylrhizoxin; patnidronic acid; panaxytriol; panomifene; parabactin;
pazelliptine;
pegaspargase; peld.esine; pentosan polysulfate sodium; pentostatin;
pentrozole; perflubron;
perfosfamide; perillyl alcohol; phenazinomycin; phenylacetate; phosphatase
inhibitors;
picibanil; pilocarpine hydrochloride; pirarubi.cin; piritrexim; placetin A.;
placeti.n B;
plasminogen activator inhibitor; platinum complex; platinum compounds;
platinum-triamine complex; porfimer sodium; porfiromycin; prednisone; propyl
bis-acridone; prostaglandin ;12; proteasome inhibitors; protein A-based immune
modulator;
protein kinase C inhibitor; protein kinase C inhibitors, microalgal; protein
tyrosine
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phosphatase inhibitors; purine nucleoside phosphorylase inhibitors; purpurins;
pyrazoloacridine; pyridoxylated hemoglobin polyoxyethylene conjugate; raf
antagonists;
raltitrexed; ramosetron; ras fam.esyl protein transferase inhibitors; ras
inhibitors; ras-GAP
inhibitor; retelliptine demethylated; rhenium Re 186 etidronate; rhizoxin;
ribozymes; R11
retinamide; rohitukine; romurtide; roquinim.ex; rubiginone Bl; ruboxyl;
safingol; saintopin;
SarCNU; sarcophytol A; sargramostim; Sdi 1 mimetics; semustine; senescence
derived
inhibitor 1; sense ol.igonucleotides; signal transduction inhibitors;
sizofiran.; sobuzoxane;
sodium borocaptate; sodium phenylacetate; solverol; somatomedin binding
protein;
sonermin; sparfosic acid; spicamycin. D; spiromustin.e; splenopentin.;
spon.gistatin 1;
squalamine; stipiamide; stromelysin inhibitors; sulfinosine; superactive
vasoactive intestinal
peptide antagonist; suradista; suramin; swainsonine; tallimustine; tamoxifen
methiodide;
tauromustine; tazarotene; tecogalan sodium; tegafur; tellurapyrylium;
telomerase inhibitors;
temoporfin; teniposide; tetrachlorodecaoxide; tetrazomine; thaliblastine;
thiocoraline;
thrombopoietin; thrombopoietin mimetic; thymal.fasi.n; thymopoietin receptor
agonist;
thymotrinan; thyroid stimulating hormone; tin ethyl etiopurpulin;
tirapazamine; titanocene
bichloride; topsenti.n; toremifene; translation inhibitors; tretinoin;
triacetyluridin.e;
triciribine; trimetrexate; triptorelin; tropisetron; turosteride; tyrosine
kinase inhibitors;
tyrphostins; .UBC inhibitors; uben.imex; urogenital sinus-derived growth
inhibitory factor;
urokinase receptor antagonists; vapreotide; variolin B; velaresol; veramine;
verdins;
verteporfin; vinorelbine; virixaltine; vitaxin; vorozole; zanoterone;
zeniplatin; zilascorb; and
zi.nostatin. stimalamer.
[00194] Specific additional therapeutic agents include, but are not limited
to, oblimersen
(Genasense!), rem.icade, docetaxel, celecoxib, melphalan, dexamethasone
(Decadroe),
steroids, gemcitabine, cisplatinum, temozolomide, etoposide, cyclophosphamide,
temodar,
carboplatin, procarbazine, gl.iadel, tamoxifen, topotecan, methotrexate, Arisa
, taxol,
taxotere, fluorouracil, leucovorin, irinotecan, xeloda, CPT-11, interferon
alpha, pegylated
interferon alpha (e.g., PEG 1NTRON-A), capecitabine, cisplatin., th.iotepa,
fludarabin.e,
carboplati.n, I.iposomal daunorubicin, cytarabin.e, doxetaxol, pacilitaxel,
vinblastine, 1L-2,
GM-CSF, dacarbazine, vinorelbine, zoledronic acid, palmitronate, biaxin,
busulphan,
prednisone, bisphosphonate, arsenic trioxide, vin.cristine, doxorubicin (Doxil
), pacli.taxel,
ganciclovir, adriamycin, estramustine sodium phosphate (Emcyt ), sulindac, and
etoposide.
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D. Methods of Use
[00195] The combination of 5-azacytidine, or a pharmaceutically acceptable
salt, solvate
or hydrate thereof with one or more additional therapeutic agent(s), including
an anti-PD1
or anti-PDL1 monoclonal antibody, provided herein can be used in all the
methods as
provided herein. Particularly, the combination of 5-azacytidine, or a
pharmaceutically
acceptable salt, solvate or hydrate thereof with one or more additional
therapeutic agent(s),
including an anti-PD I or anti-PDL1 monoclonal antibody provided herein can be
used in
the treatment, prevention or improvement of all diseases disorders, or
conditions provided
herein.
[00196] In one embodiment, a method for treating a subject having a disease or
disorder,
wherein the method comprises cyclically administering to the subject a
therapeutically
effective amount of a cytidine analog (e.g., 5-azacytidine), or a
pharmaceutically acceptable
salt, solvate or hydrate thereof, and a therapeutically effective amount of
one or more
therapeutic agent(s), including an anti-PD1/anti-PDL1 monoclonal antibody,
wherein the 5-
azacytidine, or a pharmaceutically acceptable salt, solvate or hydrate thereof
is administered
orally.
[00197] In one embodiment, the disease or disorder is a solid tumor.
[00198] In one embodiment, the disease or disorder is a hematological
disorder.
[00199] In one embodiment, the disease or disorder is myelodysplastic
syndromes, acute
myeloid leukemia, ovarian cancer, or non-small cell lung cancer.
[00200] In one embodiment, the disease or disorder is relapsed or refractory.
[00201] In one embodiment, the subject having a disease or disorder did not
respond to a
prior treatment.
[00202] In one embodiment, the prior treatment comprises an injectable
hypomethylating
agent.
[00203] In one embodiment, the prior treatment comprises a platinum based
regimen.
[00204] In one embodiment, the ovarian cancer is epithelial ovarian cancer.
[00205] In one embodiment, the epithelial ovarian cancer is relapsed
epithelial ovarian
cancer.
[00206] In one embodiment, the relapsed or refractory epithelial ovarian
cancer followed
a prior treatment comprising a platinum based regimen.
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[00207] In one embodiment, the relapsed or refractory non-small cell lung
cancer
followed a prior treatment comprising a platinum based regimen.
[00208] In one embodiment, the relapsed or refractory epithelial ovarian
cancer followed
a prior treatment comprising an injectable hypomethylating agent.
[00209] In one embodiment, the relapsed or refractory non-small cell lung
cancer
followed a prior treatment comprising an injectable hypomethylating agent.
[00210] In one embodiment, the relapsed or refractory myelodysplastic
syndromes
followed a prior treatment comprising an injectable hypomethylating agent.
[00211] In one embodiment, the relapsed or refractory acute myeloid leukemia
followed
a prior treatment comprising an injectable hypomethylating agent.
[00212] In one embodiment, the relapsed or refractory myelodysplastic
syndromes
followed a prior treatment comprising a platinum based regimen.
[00213] In one embodiment, relapsed or refractory acute myeloid leukemia
followed a
prior treatment comprising a platinum based regimen.
[00214] In one embodiment, the anti-PD! monoclonal antibody is a humanized
monoclonal IgG4 antibody.
[00215] In one embodiment, the anti-PDL1 monoclonal antibody is a humanized
monoclonal IgG I antibody.
[00216] In one embodiment, the humanized monoclonal IgG4 antibody is
pembrolizumab, MK-3475, pidilizurnab, Nivolumab (BMS-936558, MDX-1106, or ONO-
4538).
[00217] In one embodiment, the humanized monoclonal Ig04 antibody is
pembrolizumab.
[00218] In one embodiment, the humanized monoclonal IgG1 antibody is BMS-
936559,
atezolizumab (MPDL3280A), or durvalumab (MEDI4736).
[00219] In one embodiment, the humanized monoclonal IgG I antibody is
durvalumab
(MED:14736).
[00220] In one embodiment, 5-azacytidine, or a pharmaceutically acceptable
salt, solvate
or hydrate thereof is administered for 21 consecutive days followed by seven
consecutive
days of rest in a 28 day cycle.
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[00221] In one embodiment, 5-azacytidine, or a pharmaceutically acceptable
salt, solvate
or hydrate thereof is administered for 14 consecutive days followed by seven
consecutive
days of rest in a 21 day cycle.
[00222] In certain embodiments, 5-azacytidine, or a pharmaceutically
acceptable salt,
solvate or hydrate thereof is administered day I through day 7, every 4 weeks
(94W).
azacytidine will be administered at 75 mg/m2/day, day 1 through day 7, every 4
weeks
(Q4W).
[00223] In one embodiment, the anti-PDVanti-PDL1 monoclonal antibody is
administered on days 7 and 21 in a 28 day cycle.
[00224] In one embodiment, the anti-PDI/anti-PDL1 monoclonal antibody is
administered on day 1 in a 28 day cycle.
[00225] In one embodiment, the anti-PD1/anti-PDL I monoclonal antibody is
administered on days 8 and 21 in a 28 day cycle.
[00226] In one embodiment, the anti-PD1/anti-PDLI monoclonal antibody is
administered on day 1 in a 21 day cycle.
[00227] In one embodiment, the anti-PD1/anti-PDL1 monoclonal antibody is
administered on day 1 in a 14 day cycle.
[00228] In one embodiment, 5-azacytidine, or a pharmaceutically acceptable
salt, solvate
or hydrate thereof is administered for 21 consecutive days followed by seven
consecutive
days of rest in a 28 day cycle, and the anti-PDVanti-PDL1 monoclonal antibody
is
administered on day 1 of the 28 day cycle. The disease or disorder is MDS or
AML (e.g.,
relapsed or refractory MDS or AML, and, more particularly, MDS or AML that is
not
responding to treatment with injectable hypomethylating agents).
[00229] In one embodiment, 5-azacytidine, or a pharmaceutically acceptable
salt, solvate
or hydrate thereof is administered for 21 consecutive days followed by seven
consecutive
days of rest in a 28 day cycle, and the anti-PDI/anti-PDL1 monoclonal antibody
is
administered on days 7 and 21 of the 28 day cycle. The disease or disorder is
MDS or AML
(e.g., relapsed or refractory MDS or AML, and, more particularly, MDS or AML
that is not
responding to treatment with injectable hypomethylating agents).
[00230] In one embodiment, 5-azacytidine, or a pharmaceutically acceptable
salt, solvate
or hydrate thereof is administered for 21 consecutive days followed by seven
consecutive
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days of rest in a 28 day cycle, and the anti-PD1/anti-PDL1 monoclonal antibody
is
administered on days 8 and 21 of the 28 day cycle. The disease or disorder is
MDS or AML
(e.g., relapsed or refractory MDS or AML, and, more particularly, MDS or AML
that is not
responding to treatment with injectable hypomethylating agents).
[00231] In one embodiment, 5-azacytidine, or a pharmaceutically acceptable
salt, solvate
or hydrate thereof is administered for 14 consecutive days followed by seven
consecutive
days of rest in a 21 day cycle, and the anti-PD 1 /anti-PDL1 monoclonal
antibody is
administered on day 1 of the 21 day cycle. The disease or disorder is ovarian
cancer or lung
cancer (e.g., epithelial ovarian cancer or non-small cell lung cancer,
particularly, relapsed or
refractory epithelial ovarian cancer or non-small cell lung cancer, and more
particularly,
epithelial ovarian cancer or non-small cell lung cancer relapsed following a
platinum based
therapy.
[00232] In one embodiment, 5-azacytidine, or a pharmaceutically acceptable
salt, solvate
or hydrate thereof is administered day 1 through day 7, every 4 weeks (Q4W)
and the anti-
PDL1 monoclonal antibody is administered every 2 weeks. The disease or
disorder is MDS
or AML (e.g., relapsed or refractory MDS or AML, and, more particularly, MDS
or AML
that is not responding to treatment with injectable hypomethylating agents or
untreated
(first-line) higher risk MDS).
[00233] In one embodiment, the 5-azacytidine, or a pharmaceutically acceptable
salt,
solvate or hydrate thereof is administered in an amount of about 300 mg per
day for 14
consecutive days followed by seven consecutive days of rest in a 21 day cycle,
and
pembrolizumab is administered at a dose of 10 mg/kg on day 1 of the 21 day
cycle, and the
disease or disorder is relapsed epithelial ovarian cancer
[00234] In one embodiment, the 5-azacytidine, or a pharmaceutically acceptable
salt,
solvate or hydrate thereof is administered in an amount of about 100 mg twice
per day, of
about 150 mg twice per day, of about 200 mg twice per day or of about 300 mg
twice per
day for 21 consecutive days followed by seven consecutive days of rest in a 28
day cycle,
and pembrolizumab is administered at a dose of 10 mg/kg on days 7 and 21 of
the 28 day
cycle, and the disease or disorder is acute myeloid leukemia (AML) not
responding to
treatment with injectable hypomethylating agents (HMAs) or myelodysplastic
syndromes
(MDS).
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[00235] In one embodiment, the 5-azacytidine, or a pharmaceutically acceptable
salt,
solvate or hydrate thereof is administered in an amount of about 200 mg per
day for 21
consecutive days followed by seven consecutive days of rest in a 28 day cycle,
and
pembrolizumab is administered at a dose of 10 mg/kg on days 7 and 21 of the 28
day cycle,
and the disease or disorder is acute myeloid leukemia (AML) not responding to
treatment
with injectable hypomethylating agents (HMAs) or myelodysplastic syndromes
(MDS).
[00236] In one embodiment, the 5-az.acytidine, or a pharmaceutically
acceptable salt,
solvate or hydrate thereof is administered in an amount of about 200 mg per
day for 21
consecutive days followed by seven consecutive days of rest in a 28 day cycle,
and
pembrolizumab is administered at a dose of 5 mg/kg on days 7 and 21 of the 28
day cycle,
and the disease or disorder is acute myeloid leukemia (AML) not responding to
treatment
with injectable hypomethylating agents (HMAs) or myelodysplastic syndromes
(MDS).
[00237] In one embodiment, the 5-azacytidine, or a pharmaceutically acceptable
salt,
solvate or hydrate thereof is administered in an amount of about 200 mg per
day for 14
consecutive days followed by 14 consecutive days of rest in a 28 day cycle,
and
pembrolizumab is administered at a dose of 5 mg/kg on days 7 and 21 of the 28
day cycle,
and the disease or disorder is acute myeloid leukemia (AML) not responding to
treatment
with injectable hypomethylating agents (HMAs) or myelodysplastic syndromes
(MDS).
[00238] In one embodiment, the 5-azacytidine, or a pharmaceutically acceptable
salt,
solvate or hydrate thereof is administered in an amount of about 300 mg twice
per day for
21 consecutive days followed by seven consecutive days of rest in a 28 day
cycle, and
pembrolizumab is administered at a dose of 10 mg/kg on days 8 and 21 of the 28
day cycle,
and the disease or disorder is acute myeloid leukemia (AML) not responding to
treatment
with injectable hypomethylating agents (HMAs) or myelodysplastic syndromes
(MDS).
[00239] In one embodiment, the 5-az.acytidine, or a pharmaceutically
acceptable salt,
solvate or hydrate thereof is administered in an amount of about 300 mg per
day for 14
consecutive days followed by seven consecutive days of rest in a 21 day cycle,
and
pembrolizumab is administered on day 1 of the 21 day cycle, and the disease or
disorder is
non-small cell lung cancer.
[00240] In one embodiment, the 5-azacytidine, or a pharmaceutically acceptable
salt,
solvate or hydrate thereof is administered in an amount of about 200 mg twice
per day for
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21 consecutive days followed by seven consecutive days of rest in a 28 day
cycle, and
durvalumab is administered at a dose of 1500 mg per day on days 7 and 21 of
the 28 day
cycle, or durvalumab is administered at a dose of 1500 mg per day on day 1 of
the 28 day
cycle, and the disease or disorder is acute myeloid leukemia (AML) or
myelodysplastic
syndromes (MDS) not responding to treatment with injectable hypomethylating
agents
(HMAs).
[00241] In one embodiment, the 5-az.acytidine, or a pharmaceutically
acceptable salt,
solvate or hydrate thereof is administered in an amount of about 75 mg/m2/ day
for 7
consecutive days every 4 weeks (Q4W), and durvalumab is administered at a dose
of 10
mg/kg BW every 2 weeks (Q2W), and the disease or disorder is acute myeloid
leukemia
(AML) or myelodysplastic syndromes (MDS) not responding to treatment with
injectable
hypomethylating agents (HMAs).
[00242] In one embodiment, 5-azacytidine, or a pharmaceutically acceptable
salt, solvate
or hydrate thereof is administered in an amount of about 50 mg, about 100 mg,
about 200
mg, about 300 mg, about 400 mg, about 500 mg, or about 600 mg per day.
[00243] In one embodiment, 5-azacytidine, or a pharmaceutically acceptable
salt, solvate
or hydrate thereof is administered in an amount of about 300 mg per day.
[00244] In one embodiment, 5-azacytidine, or a pharmaceutically acceptable
salt, solvate
or hydrate thereof is administered in an amount of about 200 mg per day.
[00245] In one embodiment, 5-azacytidine, or a pharmaceutically acceptable
salt, solvate
or hydrate thereof, is administered once per day.
[00246] In one embodiment, 5-azacytidine, or a pharmaceutically acceptable
salt, solvate
or hydrate thereof, is administered twice per day.
[00247] In one embodiment, 5-azacytidine or a pharmaceutically acceptable
salt, solvate
or hydrate thereof is administered in an amount of about 200 mg, about 150 mg,
or about
100 mg twice per day. In one embodiment, 5-azacytidine or a pharmaceutically
acceptable
salt, solvate or hydrate thereof is administered in an amount of about 200 mg,
twice per day.
In one embodiment, 5-azacytidine or a pharmaceutically acceptable salt,
solvate or hydrate
thereof is administered in an amount of about 150 mg twice per day. In one
embodiment, 5-
azacytidine or a pharmaceutically acceptable salt, solvate or hydrate thereof
is administered
in an amount of about 100 mg twice per day.
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[00248] In one embodiment, the anti-PDI/anti-PDL1 monoclonal antibody is
administered parenterally.
[00249] In one embodiment, the anti-PD1/anti-PDL I monoclonal antibody is
administered in an amount of about 0.5 mg of anti-PD1/anti-PDL1 monoclonal
antibody per
kilogram of a subject's mass, about 1 mg/Kg, about 2 mg/Kg, about 3 mg/Kg,
about 4
mg/Kg, about 5 mg/Kg, about 6 mg/Kg, about 7 mg/Kg, about 8 mg/Kg, about 9
mg/Kg,
about 10 mg/Kg, about 11 mg/Kg, about 12 mg/Kg, about 13 mg/Kg, about 14
mg/Kg,
about 15 mg/Kg, about 16 mg/Kg, about 17 mg/Kg, about 18 mg/Kg, about 19
mg/Kg, or
about 20 mg/Kg.
[00250] In one embodiment, the anti-PDI/anti-PDL1 monoclonal antibody is
administered intravenously in an amount of about 10 mg/Kg per day.
[00251] In one embodiment, the anti-PD1/anti-PDL I monoclonal antibody is
administered intravenously in an amount of about 10 mg/Kg per day on days 7
and 21 in a
28 day cycle, or on days 8 and 21 in a 28 day cycle.
[00252] In one embodiment, the anti-PD! monoclonal antibody is pembrolizumab,
MK-
3475, pidilizumab, Nivolumab (BMS-936558, MDX-1106, or ONO-4538) and is
administered as a 30 minute i.v. infusion.
[00253] In one embodiment, the anti-PDL1 monoclonal antibody is BM.. S-936559,
atezolizumab (MPDL3280A), or durvalumab (MEDI4736) and is administered as a 30
minute i.v. infusion. In one embodiment, 1,500 mg of durvalurnab (MEDI4736) is
administered on Day 1 of each 28-day treatment cycle by 1-hour intravenous
(IV) infusion.
[00254] In one embodiment, 5-azacytidine or a pharmaceutically acceptable
salt, solvate
or hydrate thereof is in a form of a capsule, tablet or caplet.
[00255] In one embodiment, the method further comprises administering a
therapeutically effective amount of an additional active agent.
[00256] In one embodiment, the subject is a human.
[00257] As described herein, certain embodiments herein provide oral
formulations of
cytidine analogs useful in methods relating to, e.g., permitting different
dosing amounts
and/or dosing periods; providing alternative pharmacokinetic profiles,
pharmacodynamic
profiles, and/or safety profiles; permitting the evaluation of long-term
and/or maintenance
therapies; providing treatment regimens that maximize demethylation and/or
gene re-
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expression; providing treatment regimens that prolong continuous
demethylation; providing
new indications for cytidine analogs; and/or providing other potential
advantageous
benefits.
[00258] Provided herein are methods of treating patho-physiological conditions
manifested by abnormal cell proliferation, such as, for example, cancer,
including
hematological disorders and solid tumors, by orally administering a
pharmaceutical
formulation comprising a cytidine analog, such as, for example, 5-azacytidine,
wherein the
formulation releases the cytidine analog substantially in the stomach. Other
embodiments
herein provide methods of treating immune disorders. In particular
embodiments, the
methods provided herein involve oral administering a formulation that effects
an immediate
release of the cytidine analog. In certain embodiments, the cytidine analog
and one or more
therapeutic agents are co-administered to subjects to yield a synergistic
therapeutic effect.
The co-administered agent may be a cancer therapeutic agent dosed orally or by
injection.
[00259] In certain embodiments, methods provided herein for treating disorders
related to
abnormal cell proliferation comprise orally administering a formulation
comprising a
therapeutically effective amount of a cytidine analog. Particular therapeutic
indications
relating to the methods provided herein are disclosed herein. In certain
embodiments, the
therapeutically effective amount of the cytidine analog in the pharmaceutical
formulation is
an amount as disclosed herein. In certain embodiments, the precise
therapeutically effective
amount of the cytidine analog in the pharmaceutical formulation will vary
depending on,
e.g., the age, weight, disease and/or condition of the subject.
[00260] In particular embodiments, the disorders related to abnormal cell
proliferation
include, but are not limited to, MDS, AML, ALL, CML, leukemia, chronic
lymphocytic
leukemia (CLL), lymphoma (including non-Hodgkin's lymphoma (NHL) and Hodgkin's
lymphoma), multiple myeloma (MM), sarcoma, melanoma, carcinoma,
adenocarcinoma,
chordoma, breast cancer, colorectal cancer, ovarian cancer, lung cancer (e.g.,
non-small-cell
lung cancer and small-cell lung cancer), testicular cancer, renal cancer,
pancreatic cancer,
bone cancer, gastric cancer, head and neck cancer, and prostate cancer. In
particular
embodiment, the disorder related to abnormal cell proliferation is MDS. In
particular
embodiments, the disorder related to abnormal cell proliferation is AML.
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[00261] In certain embodiments, methods provided herein for treating disorders
of
abnormal cell proliferation comprise administering a cytidine analog using at
least two of
IV, SC and oral administration methods. For example, particular embodiments
herein
provide administering an initial treatment cycle of a cytidine analog, such
as, for example,
5-azacytidin.e, administered either SC or IV, followed by subsequent orally
administered
treatment cycles of the cytidine analog. In certain embodiments, treatment
cycles comprise
multiple doses administered to a subject in need thereof over multiple days
(e.g., 1, 2, 3, 4,
5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or greater than 14 days), optionally
followed by treatment
dosing holidays (e.g., 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, or
greater th.an 14 days).
Particular embodiments herein provide a treatment schedule comprising SC
and/or IV
administration for one, two, three, four, five, or more initial cycles,
followed by oral
administration for subsequent cycles. For example, particular embodiments
herein provide
a treatment schedule comprising SC administration for cycle 1, followed by
oral
administration for subsequent cycles. Suitable dosage ranges and amounts for
the methods
provided herein are provided throughout the specification. For example, in
certain
embodiments, the SC dose is about 75 mg/m2. In certain embodiments, the oral
dose is
about 60 mg, about 80 mg, about 120 mg, about 180 mg, about 240 mg, about 300
mg,
about 360 mg, about 480 mg, or greater than about 480 mg. In certain
embodiments, oral
doses are calculated to achieve 80%, 100%, or 120% of SC AUC.
[00262] In certain embodiments, methods of treating disorders of abnormal cell
proliferation comprises orally administering a formulation comprising a
cytidine analog
(e.g., 5-azacytidine) as single or multiple daily doses. In particular
embodiments, the
formulation(s) comprising the cytidine analog is/are orally administered once
per day, twice
per day, three times per day, four times per day, or more than four times per
day. For
example, in certain embodiments, the formulation comprising the cytidine
analog is
administered using a treatment cycle comprising administration of about 200
mg, about 300
mg, about 400 mg, about 500 mg, about 600 mg, about 700 mg, about 800 mg,
about 900
mg, or about 1,000 mg of the cytidine analog once, twice, three, or four times
per day for 7,
8,9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27,
28, 29, or 30 days.
In certain embodiments, the method of treating comprises continuous low-dose
administration. In certain embodiments, the formulation comprising the
cytidine analog is
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administered using a treatment cycle comprising administration of about 300 mg
of the
cytidine analog twice per day for 7 days. In certain embodiments, the
formulation
comprising the cytidine analog is administered using a treatment cycle
comprising
administration of about 300 mg of the cytidine analog twice per day for 14
days. In certain
embodiments, the formulation comprising the cytidine analog is administered
using a
treatment cycle comprising administration of about 300 mg of the cytidine
analog three
times per day for 7 days. In certain embodiments, the formulation comprising
the cytidine
analog is administered using a treatment cycle comprising administration of
about 300 mg
of the cytidine analog three times per day for 14 days. In certain
embodiments, methods
provided herein comprise administering a formulation comprising a cytidine
analog using
one or more of the cycles provided herein, and repeating one or more of the
cycles for a
period of, e.g., 1, 2, 3,4, 5, 6, 7, 8, 9, 10, 11, 12, or greater than 12
months.
[00263] In certain embodiments, methods herein comprise administering
particular oral
formulations provided herein to, e.g., overcome limitations associated with IV
or SC
administration of cytidine analogs. For example, IV or SC administration may
limit the
ability to deliver a cytidine analog for longer periods of time on a regular
basis, thereby
potentially limiting the maximal efficacy of the cytidine analog. Due to the
difficulties of
complying with the rigors of a prolonged IV or SC dosing schedule, prolonged
SC or IV
exposure to a cytidine analog may cause subjects (e.g., subjects with multiple
cytopenias) to
discontinue from the regimen. See, e.g., Lyons, R.M., et al., Hematologic
Response to
Three Alternative Dosing Schedules of Azacitidine in Patients With
Myelodysplastic
Syndromes, J. Clin. Oncol. (2009) (DOI:10.1200/ JC0.2008.17.1058), which is
incorporated by reference herein in its entirety. Accordingly, in certain
embodiments,
methods provided herein comprise administering an oral formulation provided
herein to
overcome these or other limitations associated with SC or IV cytidine analog
administration. For example, in certain embodiments, methods provided herein
comprise
administering daily to a subject an oral formulation provided herein for 7 or
more, 8 or
more, 9 or more, 10 or more, 11 or more, 12 or more, 13 or more, 14 or more,
15 or more,
16 or more, 17 or more, 18 or more, 19 or more, 20 or more, or 21 or more
days.
[00264] Certain embodiments herein provide methods comprising administering
oral
formulations of cytidine analogs provided herein comprising delivering the
cytidine analog
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(e.g., azacitidine) at a lower dose over a more prolonged period of time, as
compared to IV
or SC administration. In particular embodiments, such methods comprise
managing dose-
related cytopen.ias (including, e.g., dose-related cytopeni.as associated with
azacitidin.e) by
administering an oral formulation provided herein. In certain embodiments,
methods
provided herein comprise administering an oral formulation provided herein to
achieve an
improved safety profile as compared to an IV or SC dose comprising the same
cytidine
analog.
[00265] As described herein, certain embodiments provide methods for improved
treatment of particular diseases or disorders (e.g., treatment of solid
tumors) by
administering an oral formulation provided herein, as compared to IV or SC
administration
of the cytidine analog. In particular embodiments, certain methods herein
provide
administering oral formulations provided herein at lower doses for more
prolonged periods
of time, leading to improved demethylation. For example, certain methods
provided herein
comprise administering an oral formulation provided herein to treat a solid
tumor while
avoiding certain dose-limiting-toxicity-related side effects associated with
dosing the
cytidine analog via SC or IV administration. An example of certain toxicity-
related
drawbacks associated with administration of a cytidine analog are described,
e.g., in K.
Appleton et al., J. Clin. Oneol., Vol. 25(29):4603-4609 (2007), which is
incorporated by
reference herein in its entirety.
[00266] Particular embodiments herein provide methods for treating a subject
having a
disease or disorder provided herein by orally administering a pharmaceutical
composition
provided herein, wherein the treatment results in improved survival of the
subject. In
certain embodiments, the improved survival is measured as compared to one or
more
conventional care regimens. Particular embodiments herein provide methods for
treating a
subject having a disease or disorder provided herein by orally administering a
pharmaceutical composition provided herein, wherein the treatment provides
improved
effectiveness. In particular embodiments, the improved effectiveness is
measured using one
or more endpoints for cancer clinical trials, as recommended by the U.S. Food
and Drug
Administration (FDA). For example, FDA provides Guidance for Industry on
Clinical Trial
Endpoints for the Approval of Cancer Drugs and Biologics
(http://www.fda.gov/CbER/gdlnsiclintrialend.htm). The FDA endpoints include,
but are not
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limited to, Overall Survival, Endpoints Based on Tumor Assessments such as (i)
Disease-
Free Survival (ii) Objective Response Rate, (iii) Time to Progression and
Progression-Free
Survival and (iv) Time-to-Treatment Failure. Endpoints Involving Symptom
Endpoints
may include Specific Symptom Endpoints such as (i) Time to progression of
cancer
symptoms and (ii) A composite symptom endpoint. Biomarkers assayed from blood
or
body fluids may also be useful to determine the management of the disease.
[00267] In certain embodiments, the methods of treating disorders of abnormal
cell
proliferation comprise orally administering a formulation of a cytidine analog
with food. In
certain embodiments, the methods of treating disorders of abnormal cell
proliferation
comprise orally administering a formulation of a cytidine analog without food.
In certain
embodiments, pharmacological parameters (e.g., Cmax, Tmax) depend on the fed
state of
the subject. In certain embodiments, the formulation of the cytidine analog is
administered
sublingually.
[00268] In certain embodiments, the cytidine analog, e.g., 5-azacytidine, is
not co-
administered with a cytidine deaminase inhibitor. In certain embodiments, the
oral
formulation comprising a cytidine analog as provided herein is not co-
administered with
THU. Certain embodiments herein provide methods of treating a disease or
disorder
provided herein (e.g., a disease associated with abnormal cell proliferation)
comprising
orally administering a cytidine analog provided herein (e.g., 5-azacytidine)
for release
substantially in the stomach, wherein the methods achieve a particular
biological parameter
provided herein (e.g., a particular Cmaõ value, T. value, and/or AUC value
provided
herein), and wherein the methods comprise not co-administering a cytidine
deaminase
inhibitor with the cytidine analog. Certain embodiments herein provide
m.ethods of treating
a disease or disorder provided herein (e.g., a disease associated with
abnormal cell
proliferation) comprising orally administering a cytidine analog provided
herein (e.g., 5-
azacytidine) for release substantially in the stomach, wherein the methods
avoid adverse
effects associated with administering a cytidine deaminase inhibitor (e.g.,
THU) by not co-
administering the cytidine deaminase inhibitor with the cytidine analog. In
particular
embodiments, a cytidine deaminase inhibitor (e.g., THU) is co-administered
with the
cytidine analog in an amount of, e.g., less than about 500 mg/d, less than
about 200 mg/d,
less than about 150 mg/d, less than about 100 mg/d, less than about 50 mg/d,
less than about
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25 mg/d, less than about 10 mg/d, less than about 5 mg/d, less than about I
mg/d, or less
than about 0.1 mg/d.
[00269] In certain embodiments, methods provided herein comprise treating a
disorder
provided herein, including a hematologic disorder, by administering an oral
dosage form
comprising a cytidine analog to a subject in need thereof. In particular
embodiments, oral
dosage forms provided herein comprising 5-azacytidine are used to treat
subjects having
hematologic disorders. Hematologic disorders include, e.g., abnormal growth of
blood cells
which can lead to dysplastic changes in blood cells and hematologic
malignancies such as
various leukemias. Examples of hematologic disorders include, but are not
limited to, acute
myeloid leukemia (AML), acute promyelocytic leukemia (APML), acute
lymphoblastic
leukemia (ALL), chronic myelogenous leukemia (CML), chronic lymphocytic
leukemia
(CLL), myelodysplastic syndromes (MDS), and sickle cell anemia, among others.
Other
disorders that can be treated using the methods provided herein include, e.g.,
multiple
m.yeloma (MM) and non-Hodgkin's lymphoma (NHL).
[00270] In certain embodiments, methods provided herein comprise treating AML
by
administering an oral dosage form comprising a cytidine analog to a subject in
need thereof.
AML is the most common type of acute leukemia that occurs in adults. Several
inherited
genetic disorders and immunodeficiency states are associated with an increased
risk of
AML. These include disorders with defects in DNA stability, leading to random
chromosomal breakage, such as Bloom's syndrome, Fanconi's anemia, Li-Fraurneni
kindreds, ataxia-telangiectasia, and X-linked agammaglobulinemia.
[00271] In certain embodiments, methods provided herein comprise treating APML
by
administering an oral dosage form. comprising a cytidine analog to a subject
in need thereof.
APML represents a distinct subgroup of AML. This subtype is characterized by
promyelocytic blasts containing the 15;17 chromosomal translocation. This
tran.sl.ocation
leads to the generation of the fusion transcript comprised of the retinoic
acid receptor and a
sequence PML.
[00272] In certain embodiments, methods provided herein comprise treating ALL
by
administering an oral dosage form comprising a cytidine analog to a subject in
need thereof.
ALL is a heterogen.erous disease with distinct clinical features displayed by
various
subtypes. Reoccurring cytogenetic abnormalities have been demonstrated in ALL.
The
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most common cytogenetic abnormality is the 9;22 translocation. The resultant
Philadelphia
chromosome represents poor prognosis of the subject.
[00273] In certain embodiments, methods provided herein comprise treating CML
by
administering an oral dosage form comprising a cytidine analog to a subject in
need thereof
CML is a clonal m.yeloproliferative disorder of a pluripotent stem cell. CML
is
characterized by a specific chromosomal abnormality involving the
translocation of
chromosomes 9 and 22, creating the Philadelphia chromosome. Ionizing radiation
is
associated with the development of CML.
[00274] In certain embodiments, methods provided herein comprise treating MDS
by
administering an oral dosage form comprising a cytidine analog to a subject in
need thereof.
In certain embodiments, MDS includes one or more of the following
myelodysplastic
syndrome subtypes: refractory anemia, refractory anemia with ringed
sideroblasts (if
accompanied by neutropenia or thrombocytopenia or requiring transfusions),
refractory
anemia with excess blasts, refractory anemia with excess blasts in
transformation, and
chronic myelomonocytic leukemia. In certain embodiments, the MDS is higher-
risk MDS.
In certain embodiments, the methods provided herein comprise administering an
oral
dosage form comprising a cytidine analog to a subject in need thereof to
increase the
survival (e.g., prolong the life) of a subject with MDS.
[00275] In certain embodiments, methods provided herein comprise treating NHL
by
administering an oral dosage form comprising a cytidine analog to a subject in
need thereof.
Non-Hodgkin's Lymphomas (NHL) represent a heterogeneous group of malignancies
of the
lymphoid system. According to the WHO classification of hematological and
lymphoid
tumors, these diseases are classified as B-cell and T-cell neoplasms. B-cell
lymphomas
account for about 90% of all lymphomas, and the two most common histological
disease
entities are follicular lymphoma and diffuse large B-cell lymphoma.
Approximately 55,000
to 60,000 new cases of NHL are diagnosed annually in the U.S. See, e.g.,
Ansell, S.M., et
al., Mayo Cli.n. Proc., 2005, 80(8):1087-97.
[00276] In certain embodiments, methods provided herein comprise treating MM
by
administering an oral dosage form comprising a cytidine analog to a subject in
need thereof.
Multiple myel.oma is one of the most commonly diagnosed hematologic
malignancies. In
2007, in the U.S. alone, there were roughly 20,000 new MM cases and 10,000
deaths due to
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MM. The disease is characterized by, inter alia, an accumulation of malignant
plasma cells
in the bone marrow, which can lead to the overproduction of an immunoglobulin,
e.g., a
monoclonal immunoglobulin G or A. These imm.unoglobulins, also known as
paraproteins,
can be detected in the urine and blood of patients with MM. Consequences of MM
include
anemia, the development of destructive bony lesions, and renal insufficiency.
See, e.g., Rao,
K.V., American Journal of Health-System Pharmacy, 2007, 64(17):1799-1807.
[00277] In certain embodiments, methods provided herein comprise treating CLL
by
administering an oral dosage form comprising a cytidine analog to a subject in
need thereof.
Chronic lymphocytic lymphoma (CLL) is a malignancy of mature B lymphocytes and
is the
most prevalent lymphoid malignancy in the U.S. The WHO classification of B
lymphocytic
neoplasms groups B cell malignancies according to the presumed normal
counterpart of the
malignant cells. CLL is diagnosed by immunophenotype analysis of lymphocytes
from the
blood, bone marrow, or lymph nodes. See, e.g., Zent, C.S., et al., Current
Oncology
Reports, 2007, 9:345-52.
[00278] Certain embodiments herein provide methods for delivering a cytidine
analog to
a subject comprising administering to the subject in need thereof an oral
formulation
comprising a cytidine analog. In particular embodiments, oral formulations
comprise (1) a
therapeutically effective amount of a cytidine analog; and (2) an optional
drug release
controlling component capable of releasing the cytidine analog substantially
in the stomach
after a subject ingests the oral formulation comprising the cytidine analog.
Certain
embodiments herein provide a method for enhancing the oral bioavail.ability of
a cytidine
analog in a subject. Certain embodiments herein provide a method of increasing
the oral
bioavailability of a cytidine analog comprising orally administering a
pharmaceutical
composition provided herein. In certain methods provided herein, a
pharmaceutical
composition provided herein is orally administered to a subject, contacts the
biological
fluids of the subject's body, and is absorbed in the upper gastrointestinal
tract, such as, for
example, substantially in the stomach.
[00279] Certain embodiments herein provide a method of achieving a particular
exposure
value provided herein by administering an oral formulation comprising a
cytidine analog
(e.g., 5-azacytidine) provided herein. Certain embodiments herein provide a
method of
achieving a particular oral bioavailability value provided herein by
administering an oral
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formulation comprising a cytidine analog (e.g., 5-azacytidine) provided
herein. Certain
embodiments herein provide a method of achieving a particular AUC value
provided herein
by administering an oral formulation comprising a cytidine analog (e.g., 5-
azacytidi.ne)
provided herein. Certain embodiments herein provide a method of achieving a
particular
Cmax value provided herein by administering an oral formulation comprising a
cytidine
analog (e.g., 5-azacytidine) provided herein. Certain embodiments herein
provide a method
of achieving a particular Tmax value provided herein by administering an oral
formulation
comprising a cytidine analog (e.g., 5-azacytidine) provided herein.
[00280] Certain embodiments herein provide methods of treating a condition
involving
undesirable or uncontrolled cell proliferation by administering an oral
formulation
comprising a cytidine analog (e.g., 5-azacytidine) as provided herein. Such
conditions
include, e.g., benign tumors, various types of cancers such as primary tumors
and tumor
metastasis, hematological disorders (e.g. leukemia, myelodysplastic syndrome
and sickle
cell anemia), restenosi.s (e.g. coronary, carotid, and cerebral lesions),
abnormal stimulation
of endothelial cells (arteriosclerosis), insults to body tissue due to
surgery, abnormal wound
healing, abnormal angi.ogenesis, diseases that produce fibrosis of tissue,
repetitive motion
disorders, disorders of tissues that are not highly vascularized, and
proliferative responses
associated with organ transplants.
[00281] In certain embodiments, cells in a benign tumor retain their
differentiated
features and do not divide in a completely uncontrolled manner. A benign tumor
may be
localized and/or nonmetastatic. Specific types of benign tumors that can be
treated using
the methods, compositions, and formulations provided herein include, e.g.,
hemangiomas,
hepatocellular adenoma, cavernous hemangioma, focal nodular hyperplasia,
acoustic
neuromas, neurofibroma, bile duct adenoma, bile duct cystanoma, fibroma,
lipomas,
leiomyom.as, mesotheliomas, teratomas, myxomas, nodular regenerative
hyperplasia,
trachomas and pyogenic granulomas.
[00282] In certain embodiments, cells in a malignant tumor become
undifferentiated, do
not respond to the body's growth control signals, and/or multiply in an
uncontrolled
manner. The malignant tumor may be invasive and capable of spreading to
distant sites
(metastasizing). Malignant tumors may be divided into two categories: primary
and
secondary. Primary tumors arise directly from the tissue in which they are
found. A
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secondary tumor, or metastasis, is a tumor which is originated elsewhere in
the body but has
now spread to a distant organ. The common routes for metastasis are direct
growth into
adjacent structures, spread through the vascular or lymphatic systems, and
tracking along
tissue planes and body spaces (peritoneal fluid, cerebrospinal fluid, etc.).
[00283] Methylation can lead to the silencing of genes critical to cellular
control (i.e.,
epigenetic gene silencing), and can be an early event in the development of
malignant
tumors including, e.g., colorectal cancer or lung cancer. See, e.g., M.V.
Brock et al., N.
Engl. J. Med., 2008, 358(1 0:1118-28; P.M. Das et al., Mol. Cancer, 2006,
5(28); G.
Gifford et al., Clin. Cancer Res., 2004, 10:4420-26; J.G. Herman et al., N.
Engl. J. Med.,
2003, 349:2042-54; A.M. Jubb et al., J. Pathology, 2001, 195:111-34.
Accordingly, in
certain embodiments, methods herein provide using oral formulations provided
herein to
prevent or reverse epigenetic gene silencing, e.g., by reversing abnormal DNA
methyl.ation.
In specific embodiments, oral formulations provided herein are used for early
intervention
to prevent the development of cancer in patients at risk of developing cancer,
e.g., familial
polyposis or lung cancer, wherein a cause of the cancer is epigenetic gene
silencing. In
particular embodiments, such early intervention would be impractical by means
other than
oral administration (e.g., IV or SC administration). In specific embodiments,
oral
formulations provided herein are used for early intervention to prevent the
recurrence of
cancer in patients at risk for early relapse, e.g., colorectal cancer or non-
small-cell lung
cancer. In certain embodiments, the early intervention is achieved via
prolonged oral
dosing schedules, using formulations and/or methods as described herein.
Certain
embodiments provide methods for administering oral formulations provided
herein to
reverse the effect of gene silencing, e.g., in patients at risk of gene
silencing due to
epigenetic changes. In particular embodiments, methods provided herein further
comprise
administering an HDAC inhibitor compound (e.g., to restore chromatin to a
transcriptionally active configuration after reversing abnormal DNA
methylation). In
particular embodiments, the HDAC inhibitor compound is entinostat (SNDX-275;
formerly
MS-275), an oral H DAC inhibitor that acts synergistically with targeted
therapies and is
selective for cancer-relevant HDAC isofortns 1, 2, and 3. In particular
embodiments, a
synergistic effect is achieved by co-administering 5-azacytidine and an H DAC
inhibitor
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(e.g., etinostat) for the treatment of solid tumors (e.g., NSCLC) or
hematological
malignancies (e.g., MDS, CMMoL, or AML).
[00284] In certain embodiments, specific types of cancers or malignant tumors,
either
primary or secondary, that can be treated using the methods, compositions, and
formulations
provided herein include, e.g., leukemia, breast cancer, skin cancer, bone
cancer, prostate
cancer, liver cancer, lung cancer (e.g., non-small-cell lung cancer and small-
cell lung
cancer), brain cancer, cancer of the larynx, gall bladder, pancreas, rectum.,
parathyroid,
thyroid, adrenal, neural tissue, head and neck, colon, stomach, bronchi,
kidneys, basal cell
carcinoma, squ.amous cell carcinoma of both ulcerating and papillary type,
metastatic skin
carcinoma, osteo sarcoma, Ewing's sarcoma, veticulum cell sarcoma, myeloma,
giant cell
tumor, gallstones, islet cell tumor, primary brain tumor, acute and chronic
lymphocytic and
granulocytic tumors, hairy-cell tumor, adenoma, hyperplasia, medullary
carcinoma,
pheochromocytoma, mucosal neuronmas, intestinal ganglioneuromas, hyperplastic
corneal
nerve tumor, marfanoid h.abitus tumor, Wi.lm's tumor, seminoma, ovarian tumor,
leiomyoma
tumor, cervical dysplasia and in situ carcinoma, neuroblastoma,
retinoblastoma,
medulloblastoma, soft tissue sarcoma, malignant carcinoid, topical skin
lesion, mycosis
fungoides, rhabdomyosarcoma, Kaposi's sarcoma, osteogenic and other sarcoma,
malignant
hypercalcemia, renal cell tumor, polycythermia vera, adenocarcinoma,
glioblastoma
multiforma, leukemias, lymphomas, malignant melanomas, epidermoid carcinomas,
and
other carcinomas and sarcomas.
[00285] Particular embodiments herein provide using the methods, compositions,
and
formulations provided herein to treat abnormal cell proliferation due to,
e.g., insults to body
tissue during surgery for a variety of surgical procedures, including, e.g.,
joint surgery,
bowel surgery, and cheloid scarring. Proliferative responses associated with
organ
transplantation that may be treated using the methods, compositions, and
formulations
provided herein include those proliferative responses contributing to
potential organ
rejections or associated complications. Specifically, these proliferative
responses may
occur during transplantation of the heart, lung (e.g., non-small-cell lung
cancer and small-
cell lung cancer), liver, kidney, and other body organs or organ systems.
[00286] In certain embodiments, the amount of the cytidine analog in the
formulations
provided herein, the methods of administration thereof, or the methods of
treatment as set
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forth herein, is a specific dosage amount as provided herein. In certain
embodiments, oral
azacitidine dosages, methods of administration thereof, or methods of
treatment of at least
one condition, including but not limited to MDS and AML, may range, e.g.,
between about
50 mg/m2/day and about 2,000 mg/m2/day, between about 100 mg/m2/day and about
1,000
mg/m2/day, between about 100 mg/m2/day and about 500 mg/m2/day, or between
about
120 mg/m2/day and about 250 mg/m2/day. In certain embodiments, particular
dosages are,
e.g., about 120 mg/m2/day, about 140 mg/m2/day, about 150 mg/m2/day, about 180
mg/m2/day, about 200 mg/m2/day, about 220 mg/m2/day, about 240 mg/m2/day,
about 250
mg/m2/day, about 260 mg/m2/day, about 280 mg/m2/day, about 300 mg/ m.2/day,
about 320
mg/m2/day, about 350 mg/m2/day, about 380 mg/m2/day, about 400 mg/m2/day,
about 450
mg/m2/day, or about 500 mg/m2/day.
[00287] In certain embodiments, appropriate biomarkers may be used to
determine or
predict the effect of the pharmaceutical compositions comprising cytidine
analogs on the
disease state and to provide guidance to the dosing schedule. For example,
particular
embodiments herein provide a method of determining whether a patient diagnosed
with
MDS has an increased probability of obtaining a greater benefit from treatment
with a
pharmaceutical composition comprising a cytidine analog by assessing the
patient's nucleic
acid methylation status. In particular embodiments, the cytidine analog is
azacitidine. In
particular embodiments, the nucleic acid is DNA or RNA. In particular
embodiments, the
greater benefit is an overall survival benefit. In particular embodiments, the
methylation
status is examined in one or more genes, e.g., genes associated with MDS or
AML.
Specific embodiments involve methods for determining whether baseline DNA
methylation
levels influence overall survival in patients with MDS (e.g., higher risk MDS)
treated with
azacitidine. Specific embodiments provide methods for determining whether gene
promoter
methylation levels influence overall survival in patients with MDS (e.g.,
higher risk MDS).
[00288] For example, specific embodiments herein provide methods for
evaluating the
influence of gene methylation on prolonged survival in patients with MDS
(e.g., higher risk
MDS). In particular embodiments, such evaluation is used to predict overall
survival in
patients with MDS (e.g., higher risk MDS), e.g., upon treatment with a
pharmaceutical
composition comprising a cytidine analog, as provided herein. In particular
embodiments,
such evaluation is used for therapeutic decision-making. In specific
embodiments, such
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therapeutic decision-making includes planning or adjusting a patient's
treatment, e.g., the
dosing regimen, amount, and/or duration of administration of the cytidin.e
analogue.
[00289] Certain embodiments provi.de methods of identifying individual
patients
diagnosed with MDS having an increased probability of obtaining an overall
survival
benefit from cyti.dine analog treatment, using analysis of methylation levels,
e.g., in
particular genes. In specific embodiments, lower levels of nucleic acid
methylation are
associated with an increased probability of obtaining improved overall
survival following
azacitidine treatment. In particular embodiments, the increased probability of
obtaining
improved overall survival following treatment is at least a 5% greater
probability, at least a
10% greater probability, at least a 20% greater probability, at least a 30%
greater
probability, at least a 40% greater probability, at least a 50% greater
probability, at least a
60% greater probability, at least a 70% greater probability, at least an 80%
greater
probability, at least a 90% greater probability, at least at least a 100%
greater probability, at
least a 125% greater probability, at least a 150% greater probability, at
least a 175% greater
probability, at least a 200% greater probability, at least a 250% greater
probability, at least a
300% greater probability, at least a 400% greater probability, or at least a
500% greater
probability of obtaining improved overall survival following treatment, e.g.,
using a
pharmaceutical composition comprising a cytidine analog as provided herein. In
particular
embodiments, the greater probability of obtaining improved overall survival
following
treatment is a greater probability as compared to the average probability of a
particular
comparison population of patients diagnosed with :MDS. In specific
embodiments, the
comparison population is a group of patients classified with a particular
myelodysplastic
subtype, as described herein. In one embodiment, the comparison population
consists of
patients having higher risk MDS. In particular embodiments, the comparison
population
consists of a particular IPSS cytogenetic subgroup.
[00290] In particular embodiments, nucleic acid (e.g., DNA or RNA)
hyperrnethylation
status may be determined by any method known in the art. In certain
embodiments, DNA.
hypermethylation status may be determined using the bone marrow aspirates of
patients
diagnosed with MDS, e.g., by using quantitative real-time methylation specific
PCR
("qM:SP"). In certain embodiments, the methylation analysis may involve
bisulfite
conversion of genomic DNA. For example, in certain embodiments, bisulfite
treatment of
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DNA is used to convert non-methylated CpG sites to UpG, leaving methylated CpG
sites
intact. See, e.g., Frommer, M., et al., Proc. Nat'l Acad. Sci. USA 1992,
89:1827-31.
Commercially available kits may be used for such bisulfite treatment. In
certain
embodiments, to facilitate methylation PCR, primers are designed as knovvn in
the art, e.g.,
outer primers which amplify DNA regardless of methylation status, and nested
primers
which bind to methylated or non-methylated sequences within the region
amplified by the
first PCR.. See, e.g., Li et al., Bioinformatics 2002, 18:1427-31. In certain
embodiments,
probes are designed, e.g., probes which bind to the bisulfite-treated DNA
regardless of
m.ethylation. status. In certain embodiments, CpG methylation is detected,
e.g., following
PCR amplification of bisulfite-treated DNA using outer primers. In certain
embodiments,
amplified product from the initial PCR reaction serves as a template for the
nested PCR
reaction using methylation-specific primers or non-methylation-specific
primers. in certain
embodiments, a standard curve is established to determine the percentage of
methylated
molecules in a particular sample. Methods for detecting nucleic acid
m.ethylation. (e.g.,
RNA or DNA methylation) are known in art. See, e.g., Laird, P.W., Nature Rev.
Cancer
2003, 3:253-66; Belinsky, S.A.., Nature Rev. Cancer 2004, 4:1-11.
[00291] In certain embodiments, statistical analyses are performed to assess
the influence
of particular methylation levels with the potential benefit of treatment with
a particular
pharmaceutical composition comprising a cytidine analog. In certain
embodiments, the
influence of methylation on overall survival is assessed, e.g., using Cox
proportional
hazards models and Kaplan-Meier (KM) methodology.
[00292] In certain embodiments, any gene associated with MDS and/or AML may be
examined for its methylation status in a patient. Particular genes include,
but are not limited
to, CKDN2B (p15), SOCS1, CDH1 (E-cadherin), TP73, and CTNNA I (alpha-catenin).
Particular genes associated with MDS and/or AML, which would be suitable for
use in the
methods disclosed here, are known in the art.
1. Methods Comprising Co-Administering One or More Additional
Therapeutic Agents with the Oral Formulations Disclosed Herein
[00293] Certain embodiments herein provide methods of treating diseases or
disorders
disclosed herein (e.g., diseases or disorders involving abnormal cell
proliferation), wherein
the methods comprise co-administering an oral formulation disclosed herein
(such as, for
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example, an oral formulation comprising 5-azacytidine) with one or more
additional
therapeutic agents (such as, for example, an anti-PD1/anti-PDL I monoclonal
antibody, e.g.
pembroli.zumab, MK-3475, pi.dilizumab, ni.vol.umab (BMS-936558, MDX-1106, or
ONO-
4538), BMS-936559, atezolizumab (MPDL3280A), or durvalurnab (MEDI4736) to
yield a
synergistic therapeutic effect. Particular co-administered therapeutic agents
useful in the
methods disclosed herein are disclosed throughout the specification. In
particular
embodiments, the additional therapeutic agent is co-administered in an amount
that is a
therapeutically effective amount. In particular embodiments, the additional
therapeutic
agent is co-administered in a separate dosage form from the cytidine analog
dosage form
with which it is co-administered. In particular embodiments, the additional
therapeutic
agent is co-administered in a dosage form (e.g., a single unit dosage form)
together with the
cytidine analog with which it is co-administered. In such cases, the cytidine
analog (e.g., 5-
azacytidine) and the additional therapeutic agent may be co-formulated
together in the same
dosage form using methods of co-formulating active pharmaceutical ingredients,
including
methods disclosed herein and methods known in the art.
[00294] Incorporation By Reference: All disclosures (e.g., patents,
publications, and web
pages) referenced throughout this specification are incorporated by reference
in their
entireties. In addition, the following disclosures are also incorporated by
reference herein in
their entireties: (1) 2008 ASCO poster abstract by B. S. Skikne, M. R. Ward,
A. Nasser, L.
Aukerman, G. Garcia-Manero; (2) G. Garcia-Manero, M. L. Stoltz, M. R. Ward, H.
Kantarjian, and S. Sharma, Leukemia, 2008, 22, 1680-84; and (3) WO
2009/139888.
V.11. EXAMPLES
A. Example
[00295] A Phase 2 multicenter, randomized, double blind, placebo controlled
study of
immune checkpoint inhibition with pembrolizumab with or without epigenetic
priming with
oral 5-azacytidine in women with relapsed epithelial ovarian cancer is
performed.
[00296] The current study will test the hypothesis that oral 5-azacytidin.e,
an orally
bioavailable formulation of AZA, can induce MM expression in tumors of EOC
patients
and thereby enhance the response of these tumors to PD-1 inhibition with the
monoclonal
antibody pembrolizurnab.
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[00297] The objective of this study is to evaluate the activity and safety of
pembrolizurnab, alone and in combination with oral 5-azacytidine in patients
with epithelial
ovarian cancer.
[00298] Objectives The primary objectives are to estimate progression-free
survival
(PFS) in both treatment arms and to estimate the PFS hazard ratio for the
combination arm
relative to the pembrolizumab monotherapy arm. The secondary objectives are to
estimate
the overall survival (OS), objective response rate (ORR), clinical benefit
rate (CBR), and
duration of clinical benefit in both treatment arms and evaluate safety. The
exploratory
objective is to assess the impact of AIM gene expression at baseline on
response to
pembrolizurnab alone or in combination with oral 5-azacytidine.
[00299] Endpoints The primary endpoint is the determination of PFS. The
secondary
endpoints are the determination of OS, ORR, CBR, duration of clinical benefit,
and safety.
The exploratory endpoints are the determination of AIM gene expression, locus
specific
m.ethylation changes with oral 5-azacyti.dine dosing in circulating tumor DNA,
quantification and characterization of tumor-infiltrating lymphocytes.
[00300] Study Design The study will be a randomized, placebo-controlled,
parallel
group, multicenter double-blind phase 2 study. Subjects will be randomly
assigned in a 1:1
ratio to one of two treatment arms: pembrolizurnab as a 30 min i..v. infusion
on Day 1 with
oral 5-azacytidine (300 mg) or placebo administered orally on days 1 ¨ 14
every 21 days.
The study will be conducted under the guidance of a Steering Committee and an
independent Data Monitoring Committee.
[00301] Subjects Approximately 120 patients will be randomly assigned on a 1:1
basis
between the two treatment arms over approximately 20 months. The main analysis
will be
performed when a total of approximately 80 PFS events have been observed. This
number
of events is expected to be observed after randomization of the last patient.
At the time of
the PFS analysis, all secondary endpoints will also be analyzed. A follow-up
analysis for
OS will be performed when 80 OS events have been observed after randomization
of the
last patient. Estimates for PFS, ORR, CBR, and duration of clinical benefit
will be updated
at the time of OS analysis.
[00302] inclusion Criteria The inclusion criteria for the study is as follows:
1. Subject is? 18 years old at the time of signing ICF
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2. Histologically documented papillary serous epithelial ovarian cancer
3. Documented relapse within 6 months after completing platinum doublet
chemotherapy
4. ECOG performance status of 0-1
5. Measurable disease as per RECIST 1.1
6. Adequate organ functions:
a. AST (SGOT), ALT (SGPT) 5_ 2.5 x upper limit of normal range (ULN), or 5_
5 x
ULN range if liver metastasis present
b. Total bil.irubin. :5 1.5 x ULN
c. Creatinine < 1.5 x ULN
d. Potassium. within normal range, or correctable with supplements
7. Adequate bone marrow function:
e. Absolute neutrophil count? 1.5 x 109 cells/L
f. Platelets? 100 x 109 cells/L
g. Hemoglobin >9 g/d1,
Females of child bearing potential must have a negative serum pregnancy test
at screening
and comply with pregnancy prevention requirements.
[003031 Exclusion Criteria The exclusion criteria are as follows:
1. Serum albumin < 3 g/dL
2. History of CNS metastases or carcinomatous meningitis
3. History of auto-immune disorders
4. History of pneumonitis or interstitial lung disease or any other medical
condition
that requires the use of steroids
5. History of clinically significant cardiac dysfunction or thromboembolic
events
6. History of inflammatory bowel disease (e.g., Crohn's disease, ulcerative
colitis),
celiac disease, prior gastrectomy or upper bowel removal, or any other
gastrointestinal disorder that would interfere with the absorption,
distribution,
metabolism or excretion of the study drug and/or predispose the subject to an
increased risk of gastrointestinal toxicity
7. Major surgery < 2 weeks prior to randomization or subject has not recovered
from
side effects of surgery.
[003041 Treatment Regimens Monotherapy arm: pembrolizumab: administered as an
i.v. infusion over 30 minutes at a dose of 10 mg/kg on day 1 every 21 days
with matching
oral 5-azacytidine placebo. Combination arm: pembrolizumab: administered as an
i..v.
infusion over 30 minutes at a dose of 10 mg/kg on day 1 every 21 day cycle
with oral 5-
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azacytidine administered orally at a dose of 300 mg daily on days 1 ¨ 14 of
each 21 day.
cycle.
[00305] Drug Supply Details Pembrolizumab: Merck Corporation will supply
pembrolizumab for IV administration. Pembrolizumab is provided as a white to
off-white
lyophilized powder in Type 1 glass vials intended for single use only.
1?embrolizumab
powder for Injection, 50 mg/vial, is reconstituted with sterile water for
injection prior to use.
The drug product is stored as a stable lyophilized powder under refrigerated
conditions (2 C
- 8 C). 5-Azacytidine: Celgene Corporation will supply 5-azacytidine (or
matching
placebo) 100 m.g tablets for oral administration. All tablets will be packaged
in blister
packs.
[00306] Treatment Duration Subjects may be treated until radiologic disease
progression (per RECIST 1.1), the subject begins a new anticancer treatment,
withdrawal of
consent, subject refusal, physician decision, toxicity that cannot be managed
by dose delay
or dose reduction, death, or the study ends for any reason.
[00307] Post Treatment Observation Period Patients will be followed for
survival
every 12 weeks (telephone contact will be sufficient), or more frequent if
requested. During
this period, further anticancer therapy information (regimen, start and end
date) will be
collected. The median OS for patients with EOC who experience relapse within 6
months
after a cisplatin duplet chemotherapy is approximately 12.0 months.
[00308] Assessments Efficacy: Tumor assessment according to RECIST 1.1 will be
performed every 6 weeks ( 5 days) from randomization until documented disease
progression, the subject begins a new anticancer treatment, withdrawal of
consent, subject
refusal, physician decision, toxicity that cannot be managed by dose delay or
dose
reduction, death, or the study ends for any reason. Safety: All subjects will
be monitored
for adverse events, starting from the time the subject signs the informed
consent form until
28-days after the last dose of IP or the end of treatment (EOT) visit,
whichever occurs later.
A thorough evaluation of medical conditions will be conducted during screening
for
eligibility. Physical examination (source documented only), vital signs,
laboratory
assessments (e.g. serum chemistry, hematology), ECG, and ECOG performance
status will
be monitored regularly. Preventative measures will be taken to avoid pregnancy
in trial
subjects or their partners, and females of child-bearing potential will have
regular pregnancy
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testing. Pharmacokinetics: Pharmacokinetic parameters will be studied.
Biomarkers: A
fresh biopsy must be collected during the screening period of 21 days prior to
randomization from consented subjects. Blood and plasma samples will also be
collected.
[00309] Statistical Methods Since the primary objective of this study is to
estimate
instead of formally testing a hypothesis, the sample size of 120 was
determined based on
feasibility and not through a formal power calculation. The primary analysis
will be
performed when a total of approximately 80 PFS events have been documented.
This is
anticipated to occur after the randomization of the last subject. The
confidence intervals for
the hazard ratio between the combination arm and the pembrolizumab monotherapy
arm. can
be calculated based on a few hypothetical hazard ratios. PFS will be
summarized by
median value using the Kaplan-Meier method. A Cox proportional hazard model
will be
used to estimate the hazard ratio (including a two sided 95% CO between the
combination
arm and the pembrolizumab arms. Secondary endpoints of RR, CBR and duration of
clinical benefit will be assessed at the time of the PFS analysis. OS will be
reported when a
total of 80 deaths have been reported. An updated analysis of other efficacy
endpoints
(PFS, RR, CBR, duration of clinical benefit) will also be presented at the
ti.m.e of OS
analysis.
B. Example 2
[00310] A Phase 1/2 international, multicenter, single-arm study of the safety
and
tolerability of oral 5-azacitidine in combination with pembrolizumab for the
treatment of
myelodysplastic syndromes (M DS) or acute myeloid leukemia (AML), not
responding to
treatment with injectable hypomethylating agents (HMAs), is performed. See
Figure 1 for
study flow diagram.
[00311] Objectives The primary objectives in Phase I are to evaluate the
safety and
tolerability of the regimen and to define the recommended Phase H dose (RP2D)
for further
evaluation. The primary objectives in Phase II are to evaluate efficacy
measures associated
with this regimen when used to treat patients with MDS or AM.L that did not
respond to an
injectable HMA. The secondary objectives in Phase I are to evaluate efficacy
signals
observed in these initial subjects. The secondary objectives in phase II are
to evaluate
safety and tolerability of the regimen when given in sequential treatment
cycles. The
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exploratory objectives are to evaluate molecular and cellular markers in bone
marrow
and/or peripheral blood that may correlate with efficacy or resistance to the
regimen.
[00312] Endpoints The primary endpoints in Phase 11 are the determinations of
dose-
limiting as well as number, type, and severity of other adverse events
(AEs)
reported. The primary endpoints in Phase II are the determinations of overall
response rate.
The secondary endpoints in Phase I are the determinations of number, type, and
clinical
relevance of objective responses. The secondary endpoints in Phase 11 are the
determinations of survival, progression-free survival, duration of response,
number, type,
and severity of adverse events. The exploratory endpoints are biomarker
assessments.
[00313] Study Design This is a Phase I/II uncontrolled study of the
combination of oral
5-azacytidine with pembrolizumab for the treatment of patients with MDS or
AML, who
have not responded to treatment with an injectable hypomethylating agent
(HMA). Phase 1
will seek to define the RP2D for the combination regimen and to explore
biological and
clinical responses to treatment. In Phase II, the sample size will be
increased to seek proof
of concept for the treatment of HMA-refractory MDS or AML and to build on the
body of
knowledge related to the safety and tolerability of the regimen. The study
will initially
enroll 3 subjects in Dosing Cohort 0 (oral 5-azacytidine, 200 mg BID 21/28
days and
pembrolizumab 10 mg/Kg on cycle days 7 and 21 (or days 8 and 21)). See Figures
2, 3, and
4. If one of the initial 3 subjects experiences predefined dose-limiting
toxicity (DLT) in the
first treatment cycle, an additional 3 subjects will be enrolled in the
cohort. If 2 or more
first cycle DLTs are seen in any dosing cohort, the dose level will be
declared intolerable
and 3 subjects will be enrolled in next lower dosing cohort; e.g., Dosing
Cohort -1.
Otherwise the dosing cohort will be declared tolerable and will become the
starting dose for
further evaluation in Phase II. The 3-6 subjects receiving the RP2D in Phase I
will be
included in the Phase II portion of the study and will be evaluated for
efficacy and safety as
described for Phase II. A sufficient number of subjects will be included in
Phase II.
Subjects will start treatment at the RP2D from. Phase I and may have their
dose or schedule
adjusted to address toxicity. Subjects will have a bone marrow evaluation
following every 3
treatment cycles to look for signs of disease response or progression.
Hematology
parameters will be evaluated every cycle. If the subject experience a Complete
Response
(CR), dosing with pembrolizumab will be discontinued, while dosing with oral 5-
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azacytidine will continue. All treatment will be discontinued upon documented
objective
disease progression. Analysis of the primary endpoint, Overall Response Rate,
will be
conducted when the last active subject completes 6 cycles of treatment.
[00314] Inclusion Criteria The inclusion criteria for the study is as follows:
1. MDS (Int-1., Int-2, High) or AML
2. Prior injectable HMA. (4 cycles vs. 6 months)
3. Progressive Disease or Stable Disease as the best response to iHMA
4. Documented objective PD/SD vs. "worsening cytopenias, increase in blasts,
or
progression in FAB subtype"
5. Last dose of iHMA within 12 weeks (> 3 weeks to C1D1.)
6. ECOG 0, 1,2
[00315] Exclusion Criteria The exclusion criteria for the study is as follows:
1. Rapidly-progressing MDS (objective criteria vs. Inv. Judgment)
2. Prior oral decitabine
3. Prior or ongoing response to iHMA (if excluding relapse)
4. ESAs, TSAs, etc., hydroxyttrea, other monoclonals, or live vaccine within
28 days
5. Other disease therapy within 14 days
6. Systemic corticosteroids within 7 days
7. GI disorders
8. Active CNS involvement
9. Autoimm.une disorders or other requiring immunosuppression.
10. Interstitial lung disease
11. Labs
Bone marrow blasts > 30(33)%
¨ WBC > 20K4tt (30K)
¨ Serum creatinine > 2.5 x ULN (2x)
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¨ Serum total bilirubin > 1.5 x ULN
Serum aspartate aminotransferase (A.ST) or alanine aminotransferase (ALT)
> 2.5 x ULN
[00316] Treatment Regimens Pembrolizumab: administered as an i.v. infusion
over 30
minutes at a dose of 10 mg/kg on days 7 and 21 (or days 8 and 21) every 28 day
cycle with
oral 5-azacytidine administered orally at a dose of 200 mg BID on days 1 ¨21
of each 28
day cycle. Further Phase I dosing cohorts are provided in Table 3 below.
Table 3: Phase I Dosing Cohorts
Dose Level Oral 5-Azacytidine Pembrolizumab*
0 200 mg BID (21/28) 10 mg/Kg (D7, D21)
-1 150 mg BID (21/28) 10 mg/Kg (D7, D21)
-2 100 mg BID (21/28) 10 mg/Kg (D7, D21)
-3 200 mg QD (21/28) 10 mg/Kg (1)7, D21)
-4 200 mg QD (21/28) 5 mg/Kg (D7, D21)
-5 200 mg QD (14/28) 5 mg/Kg (D7, D21)
* in the event of infusion reaction, infusion, rate should be
reduced
[00317] Treatment Duration Subjects may be treated until CR, PD, withdrawal of
consent, subject refusal, physician decision, toxicity that cannot be managed
by dose delay
or dose reduction, death, or the study ends for any reason. Re-treatment upon
relapse from
CR.
[00318] Post Treatment Observation Period Q 6 weeks until PD or new therapy
(clinic
visit), then Q 12 weeks until death (telephone). Survival following disease
progression after
iiiMA therapy is 4-6 months. This may be extended with either single-agent and
we expect
synergy from the combination.
[00319] Assessments Efficacy: IWG 2006 response evaluation (bone marrow
biopsy/aspirate) will be performed after completion of dosing in Cycle 2,
Cycle 4, and
Cycle 6, then after completion of dosing in every 3rd treatment cycle (9, 12,
15, etc.) to
confirm suspected disease response or progression, and upon treatment
discontinuation.
Evaluation of hematology and hemoglobin will be performed after completion
every cycle.
Evaluation of quality of life (QoL) will be measured after every cycle.
Evaluation of anti-
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pembrolizumab antibodies will be measured after every cycle. Safety: All
subjects will be
monitored for disease progression/transformation. Physical examination (source
documented only), vital signs, laboratory assessments (e.g. serum chemistry,
hematology),
ECG, and ECOG performance status will be monitored regularly.
Pharrnacokinetics:
1?harmacokinetic parameters will be studied. See Figure 5.
C. Example 3
[00320] A Phase 2 multicenter, randomized, double blind, placebo controlled
study of
oral 5-azacytidine in combination with pembrolizumab for the treatment of non-
small cell
lung cancer is performed.
[00321] Objectives The primary objectives are to estimate progression-free
survival
(PFS) in both treatment arms and to estimate the PFS hazard ratio for the
combination arm.
relative to the pembrolizumab monotherapy arm. The secondary objectives are to
estimate
the overall survival (OS), objective response rate (ORR), clinical benefit
rate (CBR), and
duration of clinical benefit in both treatment arms and evaluate safety.
[00322] Endpoints The primary endpoint is the determination of PFS. The
secondary
endpoints are the determination of OS, ORR, CBR, duration of clinical benefit,
and safety.
[00323] Study Design The study will be a randomized, placebo-controlled,
parallel
group, multicenter double-blind phase 2 study. Subjects will be randomly
assigned in a 1:1
ratio to one of two treatment arms: pembrolizumab as a 30 min i.v. infusion on
Day 1 with
oral 5-azacytidine (300 mg) or placebo administered orally on days 1 ¨ 14
every 21 days.
The study will be conducted under the guidance of a Steering Committee and an
independent Data Monitoring Committee.
[00324] Subjects Approximately 120 patients will be randomly assigned on a 1:1
basis
between the two treatment arms over approximately 20 months. The main analysis
will be
performed when a total of approximately 80 PFS events have been observed. This
number
of events is expected to be observed after randomization of the last patient.
At the time of
the PFS analysis, all secondary endpoints will also be analyzed. A follow-up
analysis for
OS will be performed when 80 OS events have been observed after randomization
of the
last patient. Estimates for PFS, ORR, CBR, and duration of clinical benefit
will be updated
at the time of OS analysis.
D. ,Example 4
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[00325] Studies of the safety and tolerability of 5-azacitidine alone or in
combination
with durvalumab (MEDI4736) for the treatment of myelodyspl.astic syndromes
(MDS) or
acute myeloid leukemia (AML) are performed. Oral 5-azacytidin.e is used alone
or in
combination with durvalumab (MEDI4736) for patients with MDS who have not
responded
to treatment with hypomethylating agents (1-1MAs). Injectable 5-azacytidine is
used alone
or in combination with durvalumab (MEDI4736) for patients with untreated
(first-line)
higher risk MDS.
[00326] The first-line trial will also generate data from a randomized phase
II cohort for
the combination of azacitidi.ne and durvalum.ab (MEDI4736) in elderly patients
with
untreated AML who are ineligible to receive allogeneic stem cell
transplantation in
preparation for a phase III study, or for accelerated approval in the USA if
there is
outstanding efficacy.
[00327] These two indications demonstrate high unmet medical need. The
analysis of the
available scientific data supports the hypothesis that the combination of
either injectable 5-
azacytidine or oral 5-azacytidine with durvalumab will be sufficiently
synergistic to
significantly improve the lives of patients with these diseases. Based on the
limited
knowledge currently available, the exploration of the combination of immune
and
epigenetic therapies is a high priority to improve the management of MDS.
[00328] Objective The study wil obtain initial combination data on safety,
preliminary
efficacy signals and possibly relevant biomark data.
[00329] Study Design The first phase of the study includes three different
clinical trials
in three indications. Patients will be classified according to pregressive
disease (PD) or
stable disease (SD) at inclusion into the trial and evaluate response
separately for both
types.
[00330] In one trial, injectable 5-azacytidine will be administered in
combination with
durvalumab (MEDI4736) to patients who do not achieve overall response (OR)
with
durvalum.ab single agent. This would permit the generation of early safety and
efficacy
signals without competition with the other studies.
[00331] In one trial, oral 5-azacytidine will be administered, alone or in
combination,
with durvalumab in patients with higher risk MDS and HMA failure. This trial
should
generate the first efficacy signals and shall ¨ via well defmed parameters for
go/no go
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decisions - demonstrate the efficacy of the combination therapy versus oral 5-
azacyfidine
alone in a randomized phase II expansion phase. This trial will also aid with
the planning of
a subsequent phase III trial.
[00332] In one trial, a phase II trial with a safety run-in part in patients
with previously
untreated higher risk TADS to evaluate the combination of durvalumab and
injectable 5-
azacytidine. This trial should generate data in a population with better
immune function and
less resistant disease. In the same Celgene-sponsored trial the combination of
injectable
azacitidine and durvalumab versus injectable 5-azacytidine will be evaluated
in randomized
phase II design in a cohort of elderly patients with AM... (WHO defined) who
are not
candidates for allogeneic stem cell transplantation.
[00333] 5-Azacitidine will be administered to patients who do not respond (no
CR, PR or
HI after at least four cycles) or develop disease progression at any time to
durvalumab in the
current cohorts of lower risk and higher risk according to IPSS. Durvalumab
will be
administered at 10 mg/kg BW, every 2 weeks (Q2W); 5-azacytidine will be
administered at
75 mg/m2/day, day 1 through day 7, every 4 weeks (Q4W). Alternatively, in one
part oral
5-azacytidine will be administered 200 mg BID, 1-21 in 28 days (21/28 d, Q4W)
to
determine the safety of oral 5-azacytidine 200 mg BID in the patient group. In
another part,
oral 5-azacytidine will be administered 200 m.g BID, 1-21 in 28 days (21/28 d,
Q4W, de-
escalation in the case of hematological or gastrointestinal toxicity), and
durvalumab (1.5g)
will be administered every four weeks, with de-escalation if necessary.
[00334] There will be a dose de-escalation if Dur.
[00335] Treatment Duration 5-azacytidine will be administered until
progression or
intolerable toxicity. For durvalumab, subjects who achieve and maintain a
complete
response (CR), marrow complete remission (mCR), partial response (PR), SD, or
hematological improvement (H1) through the end of the 12-month treatment
period will
enter follow-up. During the initial 12 months of follow-up, if a subject has
PD, the subjects'
study treatment may be re-administered for up to another 12 months with the
sam.e
treatment guidelines followed during the initial 12-month period if the
subject fulfills the
criteria for retreatment in the setting of PD, has not received other anti-
cancer treatments for
their disease, and does not meet any of the investigational product
discontinuation criteria
for the study protocol. Only one round of retreatment will be allowed.
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E. Example 5,
[00336] A phase 2, international, multicenter, randomized, open-label,
parallel group
study to evaluate the efficacy and safety of oral azacitidine alone and in
combination with
MED14736 (durvalumab) in subjects with myelodysplastic syndromes who fail to
achieve
an objective response to treatment with azacitidine for injection or
decitabine.
[00337] Objective The primary objective of this study is to investigate the
efficacy of
oral 5-azacytidine as monoth.erapy, and in combination with anti-PD-L1
monoclonal
antibody, durvalumab, in subjects with MDS that did not respond to the most
recent
treatment with an injectable hypomethyl.ating agent (HMA. azacitidine for
injection or
decitabine), or were unable to tolerate treatment with an injectable HMA.
Further
objectives are to assess the safety and tolerability of oral 5-azacytidine
alone and in
combination with durvalumab as treatment for MDS; to describe the clinical
relevance of
objective hematologic and/or biologic responses associated with treatment with
oral 5-
azacytidine alone and in combination with durvalumab; to determine the
immtmogenicity of
durvalumab when given in combination with oral 5-azacytidine in subjects with
MDS; and
to evaluate the pharmacoki.netics of durvalumab and oral 5-azacyti.dine in
subjects with
MDS.
[00338] Study Design This is a Phase 2, international, multicenter,
randomized, parallel
group, open-label study consisting of 3 study phases: Screening, Randomized
Treatment,
and Follow-up. A Safety Run-in will explore the safety and tolerability of
oral 5-azacytidine
alone and in combination with durvalumab to confirm that there are no
overlapping or
synergistic toxicities limiting the ability of the two drugs to be delivered
in combination
(see Figure 6). Once the acceptability of the combination regimen has been
demonstrated,
enrollment to the randomized treatment phase may begin.
[00339] Throughout the study, subjects will be categorized as having
Progressive Disease
(PD) or Stable Disease (SD) according to their response to iHMA therapy given
as their
most recent treatment for MDS. Numbers of subjects with PD and SD allocated to
each
treatment arm will be monitored to enable the planned analyses for each sub-
population.
Hence there are 4 cohorts being evaluated in this study:
Monotherapy, progressive disease
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Monotherapy, stable disease
Combination therapy, progressive disease
Combination therapy, stable disease
[00340] in the randomized treatment phase, eligible subjects will receive oral
5-
azacytidine alone or in combination with durvalumab. The treatment phase will
be
conducted in 2 stages, with futility assessments for each of the 4 study
cohorts determining
whether that cohort proceeds to Stage 2 (see Figure 7). The primary analysis
will follow
completion of Stage 2 and additional analyses will be conducted approximately
12 months
after the last subject is enrolled.
[00341] This study will enroll approximately 69 to 130 subjects at up to
approximately
75 investigational sites, worldwide. A.t least 12 subjects will be included in
the safety run-in
phase of the study: 6 receiving oral 5-azacytidine monotherapy, and 6
receiving oral 5-
azacytidine durvalumab combination therapy (see Figure 6). The dose and
schedule of
oral 5-azacytidine in combination with a fixed dose of durvalumab will be
determined.
[00342] Approximately 57 subjects will be enrolled in the first stage of the
randomized
treatment phase of the study. Approximately 16 subjects with progressive
disease at study
entry and 18 with stable disease at study entry will be randomized to receive
oral 5-
azacytidine monotherapy. Approximately 9 subjects with progressive disease at
study entry
and 14 with stable disease at study entry will be randomized to receive oral 5-
azacytidine +
durvalumab combination therapy. if sufficient objective responses are observed
in one or
more cohorts, the applicable cohort(s) will be expanded in Stage 2 to include
approximately
an additional 15 subjects with progressive disease and/or 19 subjects with
stable disease in
the monotherapy arm, and approximately 8 subjects with progressive disease
and/or 7
subjects with stable disease in the combination therapy arm, for a maximum of
approximately 130 subjects (see Figure 7).
[00343] During the randomized treatment phase, PK sampling will be performed
in
approximately 10-12 subjects randomized to the combination therapy arm at
selected sites
with the required capabilities. This will enable assessment for potential drug-
drug
interactions, as well as effects of immunogenicity on PK parameters. All
efforts will be
made to include at least 5 subjects with PD and at least 5 subjects with SD at
study entry.
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[00344] Study Population The study will enroll approximately 69 to 130
subjects with
MDS who did not respond to treatment with an adequate course of therapy with
an
injectable hypomethylating agent (azacitidine for injection or decitabine) as
their last
treatment for MDS, or who were unable to tolerate treatment with an injectable
HMA
following at least 3 months of attempted treatment. At least 6 subjects will
be enrolled in
each of two treatment groups during the safety run-in phase of the study:
Monotherapy
(oral 5-azacytidine) or Combination Therapy (oral 5-azacytidine -f-
durvalumab). Every
attempt will be made to include at least 3 subjects with progressive disease
(PD) and 3
subjects with stable disease (SD) in each treatment arm. Approximately 57
subjects will be
enrolled in the first stage of the treatment phase. Enrollment will be
monitored to ensure the
proper numbers of subjects with PD and SD following iHMA therapy are included
to assess
futility in these sub-populations during Stage 1. If sufficient objective
responses are
observed in one or more cohorts (SD monotherapy, PD monotherapy, SD
combination
therapy, PD combination therapy), the applicable cohort(s) will be expanded in
the second
stage of study to include up to approximately 49 additional subjects. Again,
enrollment will
be monitored to ensure the proper numbers of subjects with PD and SD in each
cohort to
enable the planned analyses.
[00345] Length of Study The total duration of this study is expected to be
approximately 36 months. Subjects will undergo screening procedures over a
period of up
to 28 days following the signing of their informed consent document (ICD).
Eligible
subjects will continue to the safety run-in or the randomized treatment phase
of the study
where they will receive IP for up to six 28-day treatment cycles. Those who
derive benefit
from the treatment may continue IP until loss of that benefit. After treatment
discontinuation, subjects will have a 28-day follow-up visit, then be
contacted by telephone
every 4 months in the follow-up phase of the study. The enrollment period for
this study is
expected to last approximately 24 months. The treatment and follow-up phases
of study are
expected to conclude approximately 12 months after the last subject is
enrolled. Therefore,
the total duration of the study is expected to be approximately 36 months. The
End of Trial
is defined as either the date of the last visit of the last subject to
complete the study, or the
date of receipt of the last data point from the last subject that is required
for primary,
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secondary and/or exploratory analysis, as pre-specified in the protocol and/or
the Statistical
Analysis Plan (S.AP), whichever is the later date.
[00346] Study Treatment (investigational Product ¨ IP) (Oral Azacitidin0
Eligible
subjects who are assigned to the monotherapy treatment arm will receive oral 5-
azacytidine at
the dose and schedule identified during the safety run-in phase of the study.
Dose and
schedule may be adjusted in order to manage toxicity. Subjects who tolerate
treatment with
oral 5-azacytidine but show signs of worsening disease (clinical or
hematological) or do not
experience hematologic improvement or better (HI) following at least 2 well-
tolerated
treatment cyles may have their dose increased. Dose and schedule can again be
reduced,
but dose-escalation beyond 300 mg BID, 21/28d may not be permitted. Subjects
can
continue treatment with oral 5-azacytidine as long as all protocol-specified
re-treatment
criteria continue to be met.
[00347] MEDI4736 (durvalumab) Eligible subjects who are assigned to the
combination
therapy treatment arm will receive oral 5-azacytidin.e as described above, and
durvalumab
1500 mg on Day 1 of each 28-day treatment cycle by 1-hour intravenous (IV)
infusion. For
toxicity that is thought to be related to treatment with durvalumab, including
immune-
related AEs (irAEs) or infusion-type reactions, the infusion of durvalumab may
be slowed
or interrupted. Dose reduction for durvalumab may not be permitted. Subjects
can continue
treatment with durvalumab in combination with oral 5-azacytidine as long as
all protocol-
specified re-treatment criteria continue to be met. If treatment with oral 5-
azacytidine is
discontinued for any reason, dosing with durvalumab will be discontinued as
well and the
subject will enter the follow-up phase of the study.
[00348] Overview of Efficacy Assessments The primary efficacy endpoint of this
trial is
the proportion of subjects achieving an objective response (HI, PR, CR, or
marrow CR ¨
modified from IWG 2006 criteria to treatment with oral 5-azacytidine alone and
in
combination with durvalumab. To assess this endpoint, bone marrow examination
will be
required prior to beginning IP and following every 2 cycles of treatment
during the first 6
treatment cycles. Subjects who continue beyond Cycle 6 will undergo bone
marrow
examination following every 3 treatment cycles or when necessary to confirm
suspected
hematologic response or disease progression. Bone marrow samples (aspirate
and/or
biopsy), along with a peripheral blood smear and pertinent clinical
information will be
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submitted for review by an independent pathologist to provide consistency in
determinations of disease classification, response, and/or progression.
Hematologic
parameters including complete blood count (CBC) with white blood cell (WBC)
differential
and platelets will be assessed by the central laboratory. To understand the
potential impact
of any immunogenic response to durval.umab on the efficacy of the treatment,
immunogenicity assessment will be performed.
[00349] Overview of Exploratory Assessments Bone marrow and peripheral blood.
samples will be collected during screening, throughout the treatment phase of
the study, and
upon treatment discontinuation. These samples will be stored for potential
future
exploratory assessments of biological markers that may impact azacitidine
efficacy
(resistance to azacitidine for injection and/or oral 5-azacytidine resistance
or sensitivity).
Identifying biological markers predictive of treatment response or failure may
enable a
more targeted approach in the use of hypomethylating agent therapy for
treatment of MDS
patients based on their individual disease characteristics. Pharmacodynamic
biomarkers of
durvalumab therapy such as the levels of soluble PD-Ll and plasma
cytokines/chemokines
will be investigated in peripheral blood samples. Exploratory mechanistic and
predictive
biomarkers of response to oral 5-azacytidine/dm-valumab combination therapy
will be
evaluated, including but not limited to PD-1/PD-L1 protein expression, gene
expression
signatures, circulating soluble proteins, genetic mutations and chromosomal
aberrations,
presence of tumor infiltrating lymphocytes, TCR clonality, and other
checkpoint molecule
expression (PD-L2, Tim-3, Lag-3, CrfLA-4) as potential mechanisms of
resistance.
[00350] All of the references cited herein are incorporated by reference in
their entirety.
While the methods provided herein have been described with respect to the
particular
embodiments, it will be apparent to those skilled in the art that various
changes and
modifications can be made without departing from the spirit and scope as
recited by the
appended claims.
[00351] The embodiments described above are intended to be merely exemplary
and
those skilled in the art will recognize or will be able to ascertain using no
more than routine
experimentation, numerous equivalents of specific compounds, materials and
procedures.
All such equivalents are considered to be within the scope and are encompassed
by the
appended claims.
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